Milligan-Morgan hemorrhoidectomy vs. hemorrhoid artery ligation and recto-anal repair: a comparative study.

BACKGROUND: Several surgical techniques for the treatment of hemorrhoidal disease (HD) have been proposed. However, the selection of the most proper technique for each individual case scenario is still a matter of debate. The purpose of the present study was to compare the Milligan-Morgan (MM) hemorrhoidectomy and the hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) technique. METHODS: A retrospective analysis of the prospectively collected database of patients submitted to HD surgery in our department was conducted. Patients were divided into two groups, the MM group and the HAL-RAR group. Primary end points were recurrence rates and patients' satisfaction rates. The Unpaired t test was used to compare numerical variables while the x2 test for categorical variables. RESULTS: A total of 124 patients were identified, submitted either to HAL-RAR or MM hemorrhoidectomy. Eight (8) patients were lost to follow up and were excluded from the analysis. Of the remaining 116 patients, 69 patients (54 males and 15 females-male / female ratio: 3.6) with a median age of 47 years old (range 18-69) were included in the HAL-RAR group while 47 patients (40 males and 7 females-male / female ratio: 5.7) with a median age of 52 years old (range 32-71) comprised the MM group. At a median follow up of 41 months (minimum 24 months-maximum 72 months), we recorded 20 recurrences (28.9%) in the HAL-RAR group and 9 recurrences in the MM group (19.1%) (p 0.229). The mean time from the procedure to the recurrence was 14.1 ± 9.74 months in the HAL-RAR group and 21 ± 13.34 months in the MM group. Patients with itching, pain or discomfort as the presenting symptoms of HD experienced statistically significantly lower recurrences (p 0.0354) and reported statistically significantly better satisfaction rates (6.72 ± 2.15 vs. 8.11 ± 1.99-p 0.0111) when submitted to MM. In the subgroup of patients with bleeding as the presenting symptom, patients satisfaction rates were significantly better (8.59 ± 1.88 vs. 6.45 ± 2.70-p 0.0013) in the HAL-RAR group. CONCLUSIONS: In patients with pain, itching or discomfort as the presenting symptoms of HD, MM was associated with less recurrences and better patients satisfaction rates compared to HAL-RAR. In patients with bleeding as the main presenting symptom of HD, HAL-RAR was associated with better patients' satisfaction rates and similar recurrence rates compared to MM.

Non-Doppler hemorrhoidal artery ligation and hemorrhoidopexy combined with pudendal nerve block for the treatment of hemorrhoidal disease: a non-inferiority randomized controlled trial.

BACKGROUND: In this study, we proposed a combined outpatient treatment modality for hemorrhoidal disease. METHODS: This study was a prospective non-inferiority randomized controlled trial (RCT). The experimental group included the dearterialization and hemorrhoidopexy under pudendal nerve block, whereas the comparator consisted of the standard Doppler guided hemorrhoidal artery ligation and hemorrhoidopexy, under spinal anesthesia. As primary hypothesis, we considered the non-inferiority of the proposed modality in terms of the presenting symptom remission rate (non-inferiority margin: 10%). Randomization was based on a 1:1 ratio. Blinding was confined to the patient and the investigator. RESULTS: Overall, 60 patients were enrolled. The primary hypothesis of this RCT (96.7% vs 73.3%) was validated. The experimental group was associated with a lower operation duration and an expedited onset of mobilization and feeding. Moreover, a favorable profile regarding short-term morbidity and analgesia was identified. The control group displayed a higher pile recurrence rate and a suboptimal patient satisfaction. A significant effect of the treatment modality in most of the SF-36 components was confirmed. CONCLUSIONS: The proposed treatment modality was associated with favorable short and long-term outcomes. Due to specific limitations, further RCTs, with a larger sample size, are required. Trial Registration ClinicalTrials.gov : NCT03298997.

Matrix metaloproteinase-2 and -9 serum levels as potential markers of intraperitoneal adhesions.

OBJECTIVE: To assess the value of matrix metalloproteinases-2 (MMP-2) and -9 (MMP-9) as prognostic serum markers for intraperitoneal adhesions. BACKGROUND: Postoperative adhesions are associated with serious complications responsible for increased patient's morbidity. METHODS: Forty-eight rabbits were used and randomized into groups A, B, C, and D. Abdominal laparotomy and experimental adhesion formation model was carried out. In group A, 60 mL of N/S 0.9% were instilled intraperitoneally, in group B 60 mL of icodextrin 4% were instilled intraperitoneally, in group C 0.1 mL/kg of dimetindene maleate were administered intravenously, and in group D both agents were administered. Prior to euthanasia 0.5 mL of blood was obtained. The type, the surface area of adhesions, and serum concentration of MMPs were assessed. RESULTS: The mean surface area and Zuhlke classification of adhesions of groups B, C, and D has been proved to be significantly lower compared to group A. Serum MMP-2 levels were significantly higher in groups B and D than in group A, while group D was higher when compared to group C. Serum MMP-9 levels were significantly higher in group D compared to groups A, B, and C. Serum MMP-9 was the most accurate test to differentiate between animals with and without adhesions with a sensitivity of 81.8% and a specificity of 100% at a cut-off point of 21.5 (AUC = 0.934). CONCLUSIONS: The administration of icodextrin 4% and dimetindene maleate seems to prevent postoperative adhesion formation. Serum levels of MMP-2 and MMP-9 may serve as prognostic markers to identify postoperative adhesions.

Acute appendicitis in a duplicated appendix.

INTRODUCTION: Double appendix represents an extremely rare and commonly "missed" diagnosis, often with life threatening consequences. PRESENTATION OF CASE: In this case report we present an interesting case of operative treatment of acute appendicitis in a doubled vermiform appendix stemming operative pitfalls. A 23-year-old female was admitted to the emergency room department complaining of diffuse abdominal pain, nausea, and vomiting over the past 36h. As soon as the diagnosis of acute appendicitis was established a laparotomy via a McBurney incision was decided. Intraoperative findings included the presence of mild quantity of free fluid and surprisingly a thin non-inflamed appendiceal process. It was the preoperative ultrasound findings suggestive of acute appendicitis that dictated a more thorough investigation of the lower abdomen that led to the discovery of a second retrocecal inflamed appendix. Formal appendectomy was then performed for both processes. The patient had an uneventful recovery and was discharged on the fourth postoperative day. DISCUSSION: Double appendix represents a challenging clinical scenario in cases of right lower quadrant pain. CONCLUSION: Life threatening consequences with legal extensions can arise from the incomplete removal of both stumps.

Diaphragmatic rupture causing repeated vomiting in a combined abdominal and head injury patient: a case report and review of the literature.

BACKGROUND: Diaphragmatic rupture after blunt abdominal injury is a rare trauma condition. Delayed diagnosis is not uncommon especially in the emergency room setting. Associated injuries often shift diagnosis and treatment priorities towards other more life-threatening conditions. CASE PRESENTATION: We present a challenging case of a young male with combined abdominal and head trauma. Repeated episodes of vomiting dominated on clinical presentation that in the presence of a deep scalp laceration and facial bruising shifted differential diagnosis towards a traumatic brain injury. However, a computed tomography scan of the brain ruled out any intracranial pathology. Finally, a more meticulous investigation with additional imaging studies confirmed the presence of diaphragmatic rupture that justified the clinical symptoms. CONCLUSIONS: The combination of diaphragmatic rupture with head injury creates a challenging trauma scenario. Increased level of suspicion is essential in order to diagnose timely diaphragmatic rupture in multiple trauma patients.

The role of the platelet-rich plasma in accelerating the wound-healing process and recovery in patients being operated for pilonidal sinus disease: preliminary results.

BACKGROUND: Because of the poor quality of life that results from the open technique (open excision and packing) for surgically treating pilonidal cyst disease, several alternatives that accelerate the wound-healing process have been proposed. This study aimed to evaluate the effect of platelet-derived growth factors on the healing process. METHODS: Fifty-two patients with pilonidal sinus disease who underwent open excision and secondary closure of the surgical wound (n = 22) or additional local postoperative infusion of platelet-derived growth factors (n = 30) were evaluated. Duration of total wound healing and time to return to normal activities were evaluated. Quality of life of patients in each group was assessed via a stabilized questionnaire. RESULTS: Wound-healing rates were much greater for the platelet group (p < 0.01). Complete healing of the surgical wound required 24 days for the platelet group while the respective time for the control group was more than 30 days (p < 0.01). Patients in the platelet group returned to their normal activities around the postoperative day 17 when mean wound volume was about 10 cc, while control group patients managed to do so around the postoperative day 25. CONCLUSIONS: These data provide evidence that the use of platelet-derived growth factors directly to the surgical wound enhances the healing process resulting in faster recovery of patients surgically treated for pilonidal sinus disease.

Low-Grade Appendiceal Mucinous Neoplasm Presenting as a Surgical Emergency: A Case Report.

We present the case of a female patient admitted to our University Hospital with acute abdominal pain mimicking an intraperitoneal septic condition caused possibly by acute appendicitis. CT and ultrasound scan showed a mass situated in the right iliac fossa. The patient was submitted to laparotomy and right hemicolectomy. The operative findings were suggestive of an appendiceal mucocele. The histology report revealed a low-grade appendiceal mucinous neoplasm. The patient had no clinical, biochemical or visual signs of disease recurrence 6 months postoperatively.

Local excision for early rectal cancer in the era of neoadjuvant strategies.

Advanced staging methodology and the evolution of new neoadjuvant therapeutic strategies have changed the management of rectal cancer. In selected cases, such as elderly patients or those denying a stoma, local excision of early rectal cancer should be considered an option in the spectrum of a multimodality treatment.

A simplified technique of RFA (radiofrequency assisted) hepatectomy.

A new technique of dividing the hepatic parenchyma in liver resections is presented. Seven liver resections in six patients were carried out, using a modification of the Radiofrequency assisted hepatectomy technique. The transection zone of the liver was coagulated prior to the division of the parenchyma using a transformed cluster cool-tip Radionics electrode. The reported technique resulted in adequate hemostasis of the raw hepatic surface and minimal blood loss. The aforementioned method seems to be quick and safe especially for local hepatic resections or segmentectomies.