Is LigaSure a safe cystic duct sealer? An ex vivo study.

BACKGROUND: To compare the efficacy and safety of both mechanical methods (clips) and electrosurgical instruments, harmonic scalpel (HS) and LigaSure (LS), for securing the cystic duct during laparoscopic cholecystectomy (LC). METHODS: During the study period from October 2010 to October 2012, 458 patients with gallbladder stones underwent LC. A total of 38 patients were excluded from the study for different reasons. The gallbladder was excised laparoscopically through the traditional method. The gallbladder specimens of the patients were divided into three equal groups randomly, and the distal part of the cystic duct was sealed ex vivo using ligaclips (Group A), HS (Group B), and LS (Group C). The gallbladders were then connected to a pneumatic tourniquet device and we very gradually increased the pressure with air. The bursting pressure of the cystic duct (CDBP) was measured and differences between the three groups were calculated. RESULTS: The mean CDBP was 329.7 ± 38.8 mmHg in the ligaclip group, 358.0 ± 33.1 mmHg in the HS group, and 219.7 ± 41.2 mmHg in the LS group. A comparison of the mean CDBP between the groups indicated the superiority of HS over ligaclip and LS. CDBP was significantly higher in the ligaclips group compared with the LS group (p <0.001). HS and ligaclips were found to be safe sealers as their mean CDBP was found to be higher (>195 mmHg) than the maximum common bile duct pressure, whereas for LS the CDBP range was 150-297 mmHg, indicating that it is not safe for sealing. CONCLUSION: HS is a safe alternative to clips. In fact, it was even safer than clips. By contrast, LS is not safe for cystic duct sealing.

Comparative study of the house advancement flap, rhomboid flap, and y-v anoplasty in treatment of anal stenosis: a prospective randomized study.

PURPOSE: Anal stenosis represents a technical challenge for surgical management. We compared the effects of house flap, rhomboid flap, and Y-V anoplasty procedures in a randomized study in patients with anal stenosis. METHODS: Consecutive patients treated for anal stenosis at our institution were evaluated for inclusion. Participants were randomly allocated to receive house flap, rhomboid flap, or Y-V anoplasty. Follow-up visits were after 1 week, 1 month, 6 months, and 1 year. Study variables included caliber of the anal canal (measured with a conical calibrator), clinical improvement, patient satisfaction (visual analog scale), incontinence (Pescatori incontinence scale), and quality of life (GI Quality of Life Inventory). RESULTS: : Sixty patients with anal stenosis were randomized and completed the study. Operative time was 62 +/- 10 minutes for house flap, 44 +/- 13 minutes for rhomboid flap, and 35 +/- 9 minutes for Y-V anoplasty (P = .042). At 1 year, anal caliber was 23.9 +/- 2.33 mm for house flap, 18.1 +/- 2.05 mm for rhomboid flap, and 16.4 +/- 2.05 mm for Y-V anoplasty (P = .04), with a highly significant increase for the house flap (P = .001). The groups differed significantly regarding clinical improvement at 1 month (95% for house flap, 80% for rhomboid flap, and 65% for Y-V anoplasty, P = .01) and differences persisted at 1 year. Significant differences were seen among groups at 1 year in GI Quality of Life Inventory scores (P = .03), with significant improvement only for the house flap (P = .01). CONCLUSION: Anal stenosis can be effectively managed with the house flap procedure, with the sole disadvantage of longer operative time. Although all 3 procedures are simple and easy to perform, the house flap appears to produce the greatest clinical improvement, patient satisfaction, and improvement in quality of life, with the fewest complications.

Effects of ovarian failure on submucosal collagen and blood vessels of the anal canal in postmenopausal women.

BACKGROUND: Estrogen and progesterone receptors are expressed in the anal canal. Fecal control deteriorates after menopause. This phenomenon is related to decreased circulating levels of estrogen and progesterone due to ovarian failure at menopause. AIM OF WORK: To study the effects of estrogen and progesterone on inflammatory cells, submucosal collagen fibers, and vascular plexus of the anal canal of postmenopausal women. SUBJECTS AND METHODS: Experiments were performed on samples of anorectal tissue obtained from 40 women, 19 menstruating (group I), and 21 postmenopausal women (group II). Investigations included immunohistochemistry of estrogen and progesterone receptors and CD34. RESULTS: In negative estrogen receptors (ER) and progesterone receptors (PR), inflammatory cells, submucosal blood vessels, collagen type I were nonsignificantly changed in postmenopausal women relative to menstruating women (P > 0.05) whereas, in positive ER and PR, inflammatory cells and collagen I were significantly increased and submucosal blood vessels were significantly decreased in postmenopausal women relative to menstruating women (P < 0.05). CONCLUSION: Estrogen and progesterone, in menstruating women, produce beneficial effects by decreasing incidence of inflammation and increasing anal canal submucosal blood vessels number and collagen types I, thus both hormones have a positive effect on anal compliance and pressure.

Randomized trial comparing LigaSure to closed Ferguson hemorrhoidectomy.

BACKGROUND: Performing hemorrhoidectomy with LigaSure vessel sealing system is a relatively new technique. The aim of the study was to evaluate LigaSure hemorrhoidectomy by comparing its results to closed Ferguson technique. PATIENTS AND METHODS: Eighty patients with grades III and IV hemorrhoids were prospectively randomized to either LigaSure or Ferguson hemorrhoidectomy. Primary end point was postoperative pain. Secondary end points were operative time, blood loss, morbidity, manometric assessment, need for analgesics, hospital stay, time to achieve complete wound healing, and patient satisfaction. RESULTS: The LigaSure group achieved a significant reduction in operative time (P < 0.001), blood loss (P < 0.001), first postoperative day pain score (P < 0.006), seventh day pain score (P < 0.012), second week pain score (P < 0.001). Less patients in the LigaSure group required pethidine analgesia on the first postoperative day (P < 0.006). Hospital stay (P < 0.001), time to achieve complete wound healing (P = 0.001) were shorter in the LigaSure group, and third month satisfaction score was higher (P = 0.03). There was no difference in postoperative complications. Postoperative manometric resting (P = 0.0001) and squeeze (P = 0.001) pressures were significantly decreased in the Ferguson group. CONCLUSION: LigaSure hemorrhoidectomy provides a valid alternative to closed hemorrhoidectomy. LigaSure patients gain short-term benefits in terms of reduced postoperative pain, wound healing, and better satisfaction. Based on our preliminary results, future studies addressing long-term functional results are needed to prove that LigaSure hemorrhoidectomy may be safer for the patients.

Utility of serum preoperative carcinoemberyonic antigen in colorectal cancer patients.

BACKGROUND/AIMS: The usefulness of preoperative CEA in CRC remains controversial as regards its biological function, and its use in the diagnosis, prognosis, and management and follow up of CRC patients. the aim of this study was to provide a critical and updated study for the value of CEA in CRC. METHODOLOGY: From January 2000 to June 2005, a prospective randomized study involving 200 CRC patients for whom curative resection was performed, another 100 healthy persons as a control group was included. Basal CEA using chemilumescence technique and routine follow up were done. RESULTS: (1) The mean basal CEA in CRC patients (17.3 ng% +/- 1.67) was significantly higher than control (3.41 ng% +/- 1.1). (2) A significant linear association between basal CEA and Dukes' classes was evident with the mean basal CEA for Dukes' A, B, C were 7.8, 12.7, 25.8 respectively (expressed as ng%). (3) The validity of basal CEA in primary CRC diagnosis was highly positive (sensitivity 80%--PPV 86.95%--accuracy 73.66%), with hig her efficacy in advanced disease detection (sensitivity 93%--NPV 7%--accuracy 84.5%--odds ratio 30.3) and negative exclusion power for DFS prediction (specificity 13.84%). (4) The basal CEA was a discriminate factor in colorectal prognosis - B value (3.74). (5) Patients with CEA < or =5 ng% had better DFS (15%) and DFT (23.6 months) than those with CEA > 5 ng% as they had DFS (33.75%) and DFT (18.48 months). (6) Basal CEA above 15 ng% had a significant shift in the cumulative hazard of recurrence. CONCLUSION: The CEA is a metastasis potentiator. The high serum CEA in CRC screening programs should be considered a marker of malignancy especially in patients with appropriate symptoms. The preop CEA in CRC patients identifies subsets with favorable, indolent and uneven biological behavior (< or =5 ng%, < or =15 ng%, > 15 ng% respectively). Moreover, the addition of preop CEA level to conventional staging forms a strong prognostic tool and supplies adopted practice guideline initiative for follow up and therapy in CRC.

Bacterial translocation in an experimental intestinal obstruction model. C-reactive protein reliability?

BACKGROUND: Bacterial translocation occurs in preseptic conditions such as intestinal obstruction through unclear mechanism. The C-reactive protein is an acute phase reactant and a marker of ischemia. METHODS: 45 albino male rats were divided into 3 groups each 15 rats. GI control, GII simple intestinal-obstruction and GIII strangulated obstruction. Outcome measures were: (1) Bacteriologic count and typing for intestinal contents, intestinal wall, liver, mesenteric lymph nodes and blood (cardiac and portal) (2) Histopathologic: mucosal injury score, inflammatory cell infiltrate in the wall, MLN, liver, (3) Biochemical: serum CRP, IL-10, mucosal stress pattern (glutathione peroxidase-malonyldialdhyde tissue levels). RESULTS: (1) Intestinal obstruction associates with BT precursors (Bact-overgrowth, mucosal-acidosis, immuno-incomptence), (2) Bacterial translocation (frequency and density) was found higher in strangulated I.O, that was mainly enteric (aerobic and anaerobic) and mostly E.coli, (3) The pathogen commonality supports the gut origin hypothesis but the systemic inflammatory response goes with the cytokine generating one. (4) The CRP median values for GI, II, III were 0.5, 6.9, 8.5 mg/L, for BT +ve 8 mg/L and 0.75 mg/L for BT -ve rats. CONCLUSION: Bacterial translocation occurs bi-directional (systemic-portal) in intestinal obstruction and the resultant inflammatory response pathogenesis is mostly 3 hit model. The CRP is a non selective marker of suspected I.O cases. However, it is a reliable marker of BT, BT density and vascular compromise during I.O.

Bacterial translocation in an experimental intestinal obstruction model: C-reactive protein reliability? / Translocação bacteriana no modelo experimental de obstrução intestinal: A proteína C-reativa é confiável?

BACKGROUND: Bacterial translocation occurs in preseptic conditions such as intestinal obstruction through unclear mechanism. The C-reactive protein is an acute phase reactant and a marker of ischemia. METHODS: 45 albino male rats were divided into 3 groups each 15 rats. GI control, GII simple intestinal-obstruction and GIII strangulated obstruction. Outcome measures were: (1) Bacteriologic count and typing for intestinal contents, intestinal wall, liver, mesenteric lymph nodes and blood (cardiac and portal) (2) Histopathologic: mucosal injury score, inflammatory cell infiltrate in the wall, MLN, liver, (3) Biochemical: serum CRP, IL-10, mucosal stress pattern (glutathione peroxidase-malonyldialdhyde tissue levels). RESULTS: (1) Intestinal obstruction associates with BT precursors (Bact-overgrowth, mucosal-acidosis, immuno-incomptence), (2) Bacterial translocation (frequency and density) was found higher in strangulated I.O, that was mainly enteric (aerobic and anaerobic) and mostly E.coli, (3) The pathogen commonality supports the gut origin hypothesis but the systemic inflammatory response goes with the cytokine generating one. (4) The CRP median values for GI, II, III were 0.5, 6.9, 8.5 mg/L, for BT +ve 8 mg/L and 0.75 mg/L for BT -ve rats. CONCLUSION: Bacterial translocation occurs bi-directional (systemic-portal) in intestinal obstruction and the resultant inflammatory response pathogenesis is mostly 3 hit model. The CRP is a non selective marker of suspected I.O cases. However, it is a reliable marker of BT, BT density and vascular compromise during I.O.

OBJETIVO: Translocação bacteriana ocorre em condições pré-sépticas como na obstrução intestinal por mecanismo não esclarecido. A proteína C-reativa é um marcador de ischemia em fase aguda. A proposição é investigar os possíveis efeitos da obstrução intestinal no equilíbrio ecológico microbiano. MÉTODOS: 45 ratos machos albinos foram distribuídos em três grupos de 15 ratos. GI controle, GII obstrução intestinal simples e GIII obstrução estrangulada. As medidas adotadas foram: (1) Contagem bacteriológica do conteúdo intestinal, parede intestinal, fígado, linfonodos mesentéricos e sangue (coração e portal) (2) Avaliação histopatológica da lesão da mucosa, infiltrado celular inflamatório da parede, linfonodos mesentéricos, fígado, (3) Avaliação bioquímica. RESULTADOS: (1) Obstrução intestinal está associada a precursora translocação bacteriana (crescimento bacteriano, acidose da mucosa, imuno-incompetência), (2) Translocação bacteriana (freqüência e densidade) foi maior na obstrução intestinal estrangulada, principalmente entérica (aeróbios e anaeróbios), sobretudo E.coli, (3) A ocorrência comum é de origem intestinal. CONCLUSÃO: A translocação bacteriana na obstrução intestinal é bi-direcional (sistêmica e portal) A proteina C-reativa não é um marcador seletivo na suspeita de obstrução intestinal. Contudo é marcador confiável da translocação bacteriana, na densidade e comprometimento durante a obstrução intestinal.

Effect of Helicobacter pylori eradication on ulcer recurrence after simple closure of perforated duodenal ulcer.

BACKGROUND: This study was conducted to elucidate the prevalence of Helicobacter pylori in patients with a perforated duodenal ulcer and to determine whether eradication of H. pylori prevent ulcer recurrence following simple repair of the perforation. PATIENTS AND METHOD: Eighty-three patients with perforated duodenal ulcer (68 males); mean age was 47.8 years+/-7.2. Antral mucosal biopsies (to determine the status of HP by rapid urease test, culture and histological examination/staining) were obtained during laparotomy by passing a biopsy forceps through the perforation site. H. pylori positive patients who had undergone patch repair were randomized into the eradication group who received amoxicillin, metranidazole plus omperazole and the control group was given omeprazole alone. Follow-up endoscopy and antral biopsies were performed at 8 weeks, 16 weeks and 1 year to show ulcer healing and determine H. pylori state. RESULTS: Of 77 patients in the study, 65 patients (84.8%) had H. pylori. These patients were randomly divided into the triple therapy group (34 patients) and the control group (31 patients). Eradication of H. pylori was significantly higher in the triple therapy group than the control group and initial ulcer healing was significantly better in the eradication group. After 1 year, ulcer recurrence was (6.1%) in the eradication group vs. (29.6%) in the control group (P=0.001). CONCLUSION: H. pylori was present in a high proportion of patients with duodenal ulcer perforation. Eradication of H. pylori after simple closure of a perforated duodenal ulcer reduced the incidence of recurrent ulcer.

Potential role of bcl-2 expression and apoptotic body index in colorectal cancer.

BACKGROUND/AIMS: Tumor growth is the result of proliferation and apoptosis. Bcl-2 is a proto-oncogene that inhibits apoptosis. The aim of the study was to investigate the clinicopathological correlations, interactions and prognostic significance of both bcl-2 protein expression and apoptotic body index (ABI) in colorectal cancer (CRCs). METHODOLOGY: Sixty colorectal cancer (CRC) patients had colonoscopic biopsies and tumor markers assay (CEA-CA19.9). The resected specimens were subjected for routine pathologic assessment, immunocytochemical staining for bcl-2 protein detection and immunofluorescence method for apoptotic body index. RESULTS: Bcl-2 immunostaining (IS) was positive in 29 patients (48.3%). The bcl-2 positive IS was significantly associated with -ve vascular invasion (P=0.05) and early tumor staging (P<0.01); the apoptotic body index had a median 3.5% and is neither correlated with bcl-2 or the clinicopathological variables. The overall survival (OS) was significantly associated with ABI (P<0.01), but not with bcl-2 expression and on bi-variant analysis, the OS is significantly better with high ABI in bcl-2 positive immunophenotype (P<0.05). CONCLUSIONS: Bcl-2 is a marker of favorable parameters (-ve angioinvasion and early tumor staging) but of no prognostic value. The apoptotic body index (ABI) is a favorable prognostic factor and may be used as a stratification parameter especially the high ABI in bcl-2 +ve CRCs.

Tibial corticotomy and periosteal elevation induce angiogenesis in chronic critical limb ischaemia.

Corticotomy and periosteal elevation as a surgical procedure for management of chronic critical limb ischaemia is a relatively new technique. The current study aimed at assessing its safety, efficiency and cost/benefit ratio. The procedure was performed in 36patients. Preoperative documentation for age, sex, co-morbidities, ankle systolic pressure, and magnetic resonance contrast angiography was obtained. Early results included evaluation of skin perfusion. Late results involved assessment of wound healing, which was documented with photographs and was graded (healed, healing, resistant, recurrent), pain (intermittent claudication and pain at rest), Kelkar score, procedure morbidity, patient satisfaction and quality of life. Mean age was 68.03 +/- 5.5 years; 23 patients were males (63.9%) and 13 females (36.1%). Twenty (55.6%) patients had ankle systolic pressure < 50 mmHg and 29 (80.5%) had infra-inguinal vascular disease. Skin perfusion improved in 33/36 patients (91.7%). At final follow-up, 34 patients (94.1%) achieved complete wound healing. Relief from ischaemic rest pain and intermittent claudication was achieved in 86.1% and 55.6% respectively, with 20 (55.6%) patients having an excellent Kelkar score. Only one patient required a major amputation. Morbidity was noted in 17.7% of cases. Patient satisfaction scores at 12 months and at final follow-up were 7.1 +/- 1.3, and 8.7 +/- 1.7 respectively, on a scale from 0 to 10. Quality of life was markedly improved as compared to the preoperative status (overall score: p = 0.05, mental health scale: p <0.05 and pain/anxiety domain: p < 0.001). The procedure appears to represent an interesting tool, which should be evaluated in randomised studies. Our findings support the postulated angiogenic effect of the fracture haematoma.