A systematic review of the literature assessing the outcomes of stapled haemorrhoidopexy versus open haemorrhoidectomy.

BACKGROUND: Symptomatic haemorrhoids affect a large number of patients throughout the world. The aim of this systematic review was to compare the surgical outcomes of stapled haemorrhoidopexy (SH) versus open haemorrhoidectomy (OH) over a 20-year period. METHODS: Randomized controlled trials published between January 1998 and January 2019 were extracted from Pubmed using defined search criteria. Study characteristics and outcomes in the form of short-term and long-term complications of the two techniques were analyzed. Any changes in trend of outcomes over time were assessed by comparing article groups 1998-2008 and 2009-2019. RESULTS: Twenty-nine and 9 relevant articles were extracted for the 1998-2008 (period 1) and 2009-2019 (period 2) cohorts, respectively. Over the two time periods, SH was found to be a safe procedure, associated with statistically reduced operative time (in 13/21 studies during period 1 and in 3/8 studies during period 2), statistically less intraoperative bleeding (3/7 studies in period 1 and 1/1 study in period 2) and consistently less early postoperative pain on the visual analogue scale (12/15 studies in period 1 and 4/5 studies in period 2) resulting in shorter hospital stay (12/20 studies in period 1 and 2/2 studies in period 2) at the expense of a higher cost. In the longer term, although chronic pain in SH and OH patents is comparable, patient satisfaction with SH may decline with time and at 2-year follow-up OH appeared to be associated with greater patient satisfaction. CONCLUSIONS: SH appears to be safe with potential advantages, at least in the short term, but the evidence is lacking at the moment to suggest its routine use in clinical practice.

Necessity of therapy for post-thyroidectomy hypocalcaemia: a multi-centre experience.

PURPOSE: Hypoparathyroidism is one of the most common and most feared complications of total thyroidectomy (TT). The aim of this study is to detect possible markers that may facilitate early tracing of hypocalcaemia-prone patients in order to reduce clinical cost by optimizing patient discharge and to avoid unnecessary treatment. METHODS: Over an 18-month period, 995 patients, 23 % male and 77 % female, aged 52.9 ± 13.4 years, underwent TT in ten Lombardy hospitals. The following parameters were analyzed: calcaemia before and 12-24 and 48 h after surgery, pre- and post-operative parathyroid hormone (PTH) at 24 h and pre-operative 25OH vitamin D. RESULTS: Mortality was nil and morbidity was 22.4 %. Mean 24-h calcaemia and PTH were 2.17 ± 0.15 mmol/l and 31.81 ± 20.35 pg/ml, respectively; mean 24-h PTH decay was 36.7 ± 34.12 %. Four hundred seventy-three (47.5 %) patients were hypocalcaemic at discharge; 142 of whom had transient hypoparathyroidism that became permanent in 27. Patients developing hypocalcaemia had significantly higher values of PTH and calcium decay. At multiple logistic regression, only 24-h calcium decay, PTH drop and the presence of symptoms and parathyroid auto-grafting were significantly related to hypoparathyroidism. The association of these factors had a 99.2 % negative predictive value (NPV) for the development of hypoparathyroidism. A 70 % PTH drop had a 93.75 NPV for transient hypoparathyroidism. A 12 % calcaemia decay had a 95.7 NPV for hypoparathyroidism. CONCLUSIONS: Hypocalcaemic asymptomatic patients with less than 70 % PTH and 12 % calcaemia decay may be safely discharged without treatment. Symptomatic patients and those with parathyroid grafting should receive calcium and vitamin D.

The clinical and dermoscopic features of invasive cutaneous squamous cell carcinoma depend on the histopathological grade of differentiation.

BACKGROUND: Little is known about the variability of the dermoscopic criteria of squamous cell carcinoma (SCC) according to the histopathological differentiation grade. OBJECTIVES: To evaluate whether specific dermoscopic criteria can predict the diagnosis of poorly differentiated SCC compared with well- and moderately differentiated SCC. METHODS: Clinical and dermoscopic images of SCCs were retrospectively evaluated for the presence of predefined criteria. Univariate and adjusted odds ratios were calculated. Discriminant functions were used to plot receiver-operator characteristic curves. RESULTS: Of 143 SCCs included, 48 (33·5%) were well differentiated, 45 (31·5%) were moderately differentiated and 50 (35·0%) were poorly differentiated. Flat tumours had a fourfold increased probability of being poorly differentiated. Dermoscopically, the presence of a predominantly red colour posed a 13-fold possibility of poor differentiation, whereas a predominantly white and white-yellow colour decreased the odds of poorly differentiated SCC by 97% each. The presence of vessels in more than 50% of the tumour's surface, a diffuse distribution of vessels and bleeding were significantly associated with poor differentiation, while scale/keratin was a potent predictor of well- or moderately differentiated tumours. CONCLUSIONS: Dermoscopy may be regarded as a reliable preoperative tool to distinguish poorly from well- and moderately differentiated SCC. Given that poor differentiation of SCC represents an independent risk factor for recurrence, metastasis and disease-specific death, identifying poorly differentiated tumours in vivo may enhance their appropriate management.

Laparoscopic vs. open appendicectomies: results obtained by junior surgeons at a British University Hospital.

BACKGROUND: The laparoscopic approach for appendicectomies remains a frequent topic of debate. In this study we report the experience with laparoscopic (LA) and open appendicectomies (OA) achieved in a British University Hospital over one year where most of these operations have been conducted by junior trainees. METHODS: Retrospective review of LA and OA performed at the Whipps Cross University Hospital of London (U.K.). Outcomes measured were the operating time, length of hospital stay and post-operative complications. RESULTS: Between January and December 2008 205 appendicectomies have been performed on adult patients. Eighty-eight per cent of the procedures were conducted by junior surgeons. The operating time was significantly shorter for the OA vs. LA patients (55 +/- 26.8 vs. 83 +/- 26.9 min, p < 0.01). The hospital stay confirmed a significant advantage for LA (2.2 vs. 3.7 days, p = 0.02). No significant differences were present among techniques for the overall morbidity, post-operative intra-abdominal abscesses and rate of readmissions. CONCLUSIONS: Under adequate supervision LA can be safely performed by junior surgeons and reduces the hospital stay.

Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing.

INTRODUCTION: Glyceryl Trinitrate (GTN) ointment has been used to treat anal fissure and pain relief in haemorrhoids, but the value of its use post-haemorrhoidectomy as an analgesic and in wound healing is unclear. The side effect of headache has often been an associated problem. Therefore, a meta-analysis of randomised controlled trials was carried out investigating the role of GTN post-haemorrhoidectomy as an analgesic, its role in would healing and the unwanted incidence of headache. METHOD: A structured literature search from 1966 to 2009, both paper and online, with no language barrier was carried out. 760 papers were identified and 5 randomised control trials which met the entry criteria were included in this study. RESULTS: A total of 333 patients were included in the meta-analysis. The results revealed that GTN ointment was statistically significant in reducing pain on Day 3 and 7 compared to the placebo group. Day 3 shows a pain score of - 1.51 (p value of 0.029) and Day 7 by - 1.66 (p value of 0.014) respectively. However, it was not significant in reducing pain on Day 1. The Odds ratio for wound healing after GTN treatment at 3 weeks was 3.57 (P < 0.0001) when compared to the placebo group. Side effect of headache was not statistically significant. CONCLUSION: This meta-analysis has shown that GTN ointment used post-haemorrhoidectomy has a significant analgesic effect in the intermediate time period (ie. Days 3-7). It also significantly improved wound healing at 3 weeks.

Crohn's disease of the vulva.

Crohn's involvement of the Vulva is unfamiliar and difficult to treat. The aim is to review the presentation, clinical course and different treatments of Vulva Crohn's disease (CD). We have reviewed the literature without language barrier from 1966 to 2009 through Pubmed with the following words: vulva and CD, vulvitis and CD, genital CD. We included articles that had Crohn's involvement of the vulva arising from a distant site (metastatic) or arising from a Crohn's fistula from the perineum and/or anorectum. We excluded CD of other gynaecological organs. One hundred thirty six abstracts were identified and related articles reviewed. Fifty-five cases of CD of the vulva were included in the final anlaysis of this review. Vulva involvement is rare and gives long-term discomfort. A combined medical therapy (metronidazole with prednisolone) appears to be the most effective treatment. The surgical approach should be reserved for non-responding cases. CD is often unrecognized cause of vulva pain and difficult to diagnose. However if diagnosed and adequately treated it usually responds to conservative therapies.

Niguarda Trauma Team: outcome of three years of activity.

BACKGROUND: The aim of this study was to prove the existence of a direct relationship between the comprehensive strategy of trauma management and an enhancement in outcome. Tests were carried out on the impact of the Niguarda Trauma Team System on mortality rates due to severe trauma. METHODS: The epidemiological data was retrospectively reviewed along with, the severity scores: Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Revised Trauma Score (RTS), Probability of survival (Ps) and the outcome of severe trauma admitted to Niguarda hospital between October 2002 and September 2005. All data were collected from the Trauma Registry of the Niguarda Hospital. Two subsequent periods of 20 and 16 months were compared. RESULTS: Nine hundred forty-two severe traumas (94.05% blunt trauma) were recorded with an overtriage rate of 36.09%. Most patients were admitted for bone and muscular injuries (52.22%). Excluding the patients who were overtriaged, there were 129 patients who died. Comparing the two periods, the Authors observed a significant reduction in mortality from 22.56% to 19.75%, mainly related to a decrease in early mortality due to hemodynamic instability. Central nervous system injury was the main cause of death (65%). Average hospital stay significantly decreased from 17.01+/-12.07 days to 14.97+/-10.34 days. CONCLUSION: Introducing a comprehensive strategy of severe trauma management, the Niguarda Trauma Team System had a significant impact on mortality rates and hospital stay.

Rectovaginal fistula in Crohn's disease.

PURPOSE: Crohn's disease is characterized by transmural bowel inflammation and a tendency to form fistulas with adjacent structures. Several different fistulas have been described: enterocutaneous, enteroenteric, enterovesical, enterovaginal, and perineal. Rectovaginal fistulas are difficult to treat despite multimodal therapy. This study was designed to review the current strategic options to best manage this condition. METHODS: We reviewed the English-language literature from 1966 to 2006, using PUBMED, targeting Crohn's disease involving vagina using key words "rectovaginal fistula and CD," "anovaginal fistula and CD," "anovaginal fistula," and "rectovaginal fistula." We excluded the involvement of the vagina from a pouch after a proctectomy. A total of 776 articles were found; 206 articles were identified and judged as being relevant on the basis of title-related articles and links were reviewed. Fifty-three articles were selected after reading the abstract or full manuscript. RESULTS: The management of rectovaginal fistula, representing 9 percent of all fistulas, remains a challenge in the setting of Crohn's disease. Medical treatments are not favorable with low rates of long-term symptomatic control and unacceptable high rates of recurrence. Several novel and new surgical techniques have been described, and rectal advancement flap, in selected patients, seems to have the most successful results. CONCLUSIONS: The management of rectovaginal fistula of Crohn's origin should involve both gastroenterologists and coloproctologists, with the best surgical results being achieved in patients receiving optimum medical therapy. More focused studies targeting these patients with the use of combined medical and surgical therapy are necessary.

Bronchoscopically-guided conformal radiation therapy for radiographically occult lung carcinoma.

Radiographically occult lung carcinoma has a very good prognosis after complete surgical resection. In medically inoperable patients three-dimensional conformal radiation therapy cannot be performed, as computed tomography scan images fail to localize the disease. Presented here is an original technique of marking radiographically occult tumors by fiberoptic bronchoscopy, applied on four patients. No short-term complications were recorded. All the patients are alive, with no evidence of disease, after a mean follow-up of 15 months.

Latissimus dorsi reverse flap to substitute the diaphragm after extrapleural pneumonectomy.

BACKGROUND: The standard procedure for diaphragm reconstruction after extrapleural pneumonectomy for a malignancy consists of the use of prosthetic patches. Our original technique utilizing the reverse flap of the latissimus dorsi is evaluated. METHODS: Once the extrapleural pneumonectomy is performed, the distal portion of the latissimus dorsi, which has been divided with a standard posterolateral thoracotomy at the level of the fifth to sixth rib, is elevated into the chest through the passage obtained by resection of the tenth rib and sutured to the lower pericardium and to the chest wall. Nine patients were evaluated. RESULTS: No operative death occurred. No flap-related complication nor infection was postoperatively assessed. Six patients received adjuvant radiotherapy. No late complication was observed. CONCLUSIONS: The distal latissimus dorsi can be used for total reconstruction of one hemidiaphragm, ensuring a watertight separation between the pleural and peritoneal cavities and avoiding paradoxical respiratory motion. In our opinion, the technique was easier, faster, and more reliable than the standard procedure employing prosthetic materials. We recommend that the procedure be integrated with the standard technique of extrapleural pneumonectomy.

Intrathoracic benign metastasizing leiomyoma with extrapulmonary growth pattern. A case report.

The authors report a case of a woman in whom complete resection of an extrapulmonary differentiated leiomyomatous tumor of uterine origin was performed 39 years after hysterectomy for uterine leiomyomas.

Extrapericardial solitary fibrous tumour of the pericardium.

Solitary fibrous tumour (SFT) occurs most commonly in the pleura and is extremely rare in the pericardium. The authors report a case of a 60-year-old man in whom a large mediastinal mass was accidentally discovered. Computed tomography showed involvement of the left anterosuperior mediastinum with displacement of the trachea, large vessels and oesophagus; histopathological findings after complete resection of the neoplasia demonstrated an SFT of the pericardium, the first reported case with extrapericardial pattern of growth. A review of the literature on SFTs of the pericardium is provided.

[Fetal alcohol syndrome and fetal alcohol effects: importance of early diagnosis and nutritional treatment]. / Sindrome de alcoholismo fetal y efectos del alcohol sobre el feto: importancia del diagnóstico precoz y del manejo nutricional.

BACKGROUND: Fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE) encompass a pattern of birth defects in persons whose mothers ingested alcohol during pregnancy. People with FAE display fewer of the FAS traits. AIM: To assess the prevalence and features of these affections in a secondary nutritional recovery centre. PATIENTS AND METHODS: All charts of children admitted between 1985 and 1995 were reviewed, and those children diagnosed as having a FAS or FAE by a geneticist were considered for this study. Birth, maternal, social and economic characteristics, psychomotor abilities (using Denver test) and response to nutritional treatment were assessed. RESULTS: During the study period, 1572 infants were admitted to the centre, and 1.97% (70% female) were diagnosed as having a FAS or FAE. These infants were admitted at 11.1 +/- 4.5 months of age and discharged after 96.7 +/- 58.1 months of hospitalisation. Mean mother's age was 33 +/- 7 years, and all belonged to low socioeconomic levels. Mean birth weight was 2048 +/- 431 g and 2469 +/- 619 g in children with FAS and FAE respectively (p < 0.03). Children with FAE performed better for gross and fine motor abilities than those with FAS. No differences were observed for language performance. Sixty five percent of children with FAS and 71% of children with FAE had an adequate weight and height increment during nutritional therapy. A multiple regression analysis showed that age at admission and gestational age were significant predictors of weight gain during therapy. CONCLUSIONS: Alcohol has teratogenic effects on the foetus that affect craneal size and psychomotor development. Alcohol also affects pre and post natal growth.

Pancoast tumours: clinical assessment and long-term results of combined radiosurgical treatment.

BACKGROUND: Many oncologists have now accepted a combined radiosurgical approach as the treatment of choice in patients with Pancoast tumour but most reports show an incorrect assessment of the disease. METHODS: Stage III lung cancer was classified as Pancoast tumour if the pulmonary extent was limited to the upper apical segment and if at least one of the features of Pancoast syndrome, indicating tumour spread to the para-apical structures, was present. Between 1984 and 1988 15 consecutive patients were treated with primary radiotherapy followed by surgery or with primary excision and subsequent radiotherapy in the absence of an initial histological diagnosis. RESULTS: The mortality of patients given the combined treatment was 6.6% (one death due to pulmonary embolism), and the five year survival rate was 26.6% for all patients and 57% for those who underwent complete resection without N2 disease. Long-term survival was 0% for those cases with incomplete resection, N2 disease, or malignant invasion of the first rib. CONCLUSIONS: Stage III lung cancer, classified as Pancoast tumour according to strict, consistent criteria, is best treated by primary radiotherapy; combined treatment should be used only for patients with potentially resectable cancer without N2 disease and/or malignant invasion of the first rib.

Re-exploration of the saphenofemoral junction in the treatment of recurrent varicose veins.

A retrospective study of 61 patients (61 legs) with recurrent varicose veins (RVV) and saphenofemoral junction (SFJ) incompetence was set up to assess the efficacy of re-exploration of the SFJ through a lateral approach. All the patients underwent re-exploration of the SFJ by a single surgeon (MPV) through a lateral approach. Thirty-one patients (50.8%) presented an intact SFJ. Twenty-seven patients (44.2%) presented intact major tributaries emerging from the stump of SFJ. In 2 patients (3.2%) the recurrence was related to neovascularization and in 1 case (1.6%) to cross groin venous connection. Follow-up averaged 2.81 years. Three (4.9%) patients were lost, 56 out of 58 patients (96.55%) were asymptomatic, 2 out of 58 (3.4%) presented a new recurrence in the groin. Complete isolation of the FV to identify every tributary and ligation of the SFJ flush with the FV are essential to avoid further recurrences.

Conservative management of esophageal leaks by transluminal endoscopic drainage of the mediastinum or pleural space.

BACKGROUND: The management of postoperative leaks into the mediastinum or pleural cavities after esophageal surgery yields unsatisfactory results. A recently described method, drainage of the mediastinum or pleural cavity through suture line defects, has been used in our department with eight patients. METHODS: A suction tube was advanced over an endoscopically placed guide wire into the abscess from inside the esophagus, and gentle aspiration was used to remove saliva and secretions. Intravenous antibiotics and total parenteral nutrition were also given. RESULTS: The sepsis was rapidly controlled, and the abscess cavity progressively collapsed in all cases. Seven patients recovered and were discharged 34 to 61 days after operation; one died of concomitant complications. CONCLUSIONS: This method seems promising for the management of intrathoracic esophageal leaks.

Gasless laparoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. Laparoscopic gastrostomy is usually performed when PEG is contraindicated, for example, in patients with esophageal strictures, large gastric tumors, or a history of multiple abdominal surgery. We report herein a case of gasless laparoscopic gastrostomy performed for carcinoma associated with a severe respiratory distress syndrome in a malnourished patient with a tight esophageal stricture. The gasless technique uses the Laparolift System (Laparolift, Origin Medsystem, Inc.), a device composed of a fan-shaped retractor and a mechanical lifting arm that produces an abdominal wall distention resembling a truncated pyramid. Gasless laparoscopy was a safe alternative approach to CO2 pneumoperitoneum in this patient.

Safety of absorbable suture for sternal closure after pulmonary or mediastinal resection.

The reliability of polyglyconate monofilament (Maxon) suture for sternal closure was tested on 216 consecutive sternotomies, performed on 208 patients in our department from January 1986 to December 1990. The reason of sternotomy was primary lung cancer in 34 cases (16%), lung metastases in 127 (59%), and disorders of the thymus in 55 (25%). Mean age was 38 years (range 3 to 78 years); multiple lung resections were performed in 102 patients (average 7 lesions, range 2 to 30); maximum extent of the operation was pneumonectomy in 2 cases, lobectomy in 53, segmentectomy in 27, and wedge resection in 74. Prior chemotherapy had been administered in 75 cases (35%). A second sternotomy was performed in 8 cases. No cases of sternal dehiscence, sternal infection, or empyema were observed, after a median follow-up of 27 months. Overall perioperative mortality was 0.9% (2/216). Our series demonstrates the safety of polyglyconate monofilament (Maxon) suture for sternal closure. Absorbable sutures appear to be a safe alternative to steel wire closure in patients undergoing extended pulmonary or mediastinal resection.