Surgical treatment of haemorrhoids according to Longo and Milligan Morgan: an evaluation of postoperative tissue response.

OBJECTIVES: To compare by prospective randomised trial the postoperative tissue reaction of stapled vs. conventional haemorrhoidectomy. PATIENTS AND METHODS: Fifty patients with stage III haemorrhoids underwent surgery for haemorrhoids. Group 1 (n = 25) had the Milligan-Morgan procedure; Group 2 (n = 25) had a stapled haemorrhoidectomy. All patients underwent measurements of endothelial dysfunction markers including E-selectin, P-selectin and intercellular adhesion molecule (ICAM). Acute-phase proteins including C-reactive protein, orosomucoid and fibrinogen were also measured. Estimations were made prior to surgery, immediately afterward surgery and on the first and fifth postoperative days. Assessment of clinical outcome was made one month after the surgery. RESULTS: There was a postoperative increase of acute-phase reactants in both groups. The patterns of the cures of the monitored parameters appeared similar in both groups. Lower values were found in Group 1, but the difference was not statistically significant except the level of fibrinogen on day 5, which was significantly higher in Group 2. E-selectin, P-selectin and ICAM showed similar time curves. Statistical analysis found the differences to be significant only when individual days were compared and not for the types of surgery. Raised ICAM and P-selectin on the fifth postoperative day was found in both groups. In Group 1, pain assessment by patients remained in the lower part of the pain rating scale, while in Group 2 it did not start declining until one week after surgery and became normal in the third to fourth weeks. In Group 1, the duration of hospitalization and the duration of incapacity for work were 50% of the values in Group 2. CONCLUSION: Patients having stapled haemorrhoidectomy have less pain and experience more rapid recovery when compared to classical haemorroidectomy. This was mirrored by the acute-phase protein CRP and fibrinogen levels postoperatively. There was no significant difference in other acute-phase reactants monitored, nor was there any difference in parameters of endothelial dysfunction. The techniques differ in extent of pain and duration of hospital stay and incapacity for work.

[Initial empirical antimicrobial therapy with piperacillin/tazobactam in intra-abdominal infections due to perforation of the large intestine and rectum and in postoperative complications after resection of the large intestine and rectum]. / Iniciální empirická antimikrobní lécba piperacilinem/tazobaktamem u nitrobrisních infekcí z perforace tlustého streva a konecníku a u pooperacních komplikací po resekci tlustého streva a konecníku.

One of the basic therapeutic procedures in surgical intraabdominal infections is early administration of antimicrobial drugs. The basic requirement for the selection of antimicrobial drugs is a broad-spectum bactericide action with low toxicity. Within the framework of a retrospective non-comparative investigation the action of the betalactam antibiotic piperacillin combined with the betalactamase inhibitor tazobactam was tested which was used in the initial empirical antimicrobial treatment of 33 patients with intraabdominal infectious complications caused by perforation of the large bowel or dehiscence of the anastomosis on the large intestine or rectum. Twenty-eight patients developed diffuse inflammation of the peritoneum (caused by perforation of a diverticulum in 17, by dehiscence of the anastomosis on the large intestine and rectum after resection on account of carcinoma in 7, by a penetrating injury of the large bowel and rectum in 3 and by postirradiation necrosis of the rectum in one female patient). Five patients developed an intraabdominal abscess as a complication of diverticulitis of the large intestine or as a postoperative infectious complication after resection of the large bowel and rectum. All patients were operated (resection of the large bowel according to Hartmann, or stoma above the site of injury or dehiscence of the intestinal anastomosis or drainage of the abscess). After surgery administration of piperacillin/tazobactam (4.5 g, subsequently after 8 hours). The period of administration was on average 8 days (5 to 11 days). After surgery the contents of the peritoneal cavity were collected for bacteriological examination incl. evaluation of the sensitivity of the isolated bacteria to piperacillin/tazebactam. From the isolated pathogens 58% were Gram-negative aerobic bacteria, in 24% anaerobic bacteria and in 18% enterococci. In 3 patients antimicrobial treatment was because of resistance of isolated bacteria to piperacillin/tazobactam (Klebsiella species, Pseudomonas aeruginosa) combined with aminoglycosides (amikacin, netilmicin). Postoperative complications developed in 9 patients (27%), incl. 3 who died (9%). In patients with intraabdominal infection caused by perforation of the large bowel and rectum or dehiscence of the anastomosis after resection of the large bowel and rectum piperacillin/tazobactam is the antibiotic of choice for the initial empirical antimicrobial treatment on account of its great efficacy against the majority of isolated bacteria, its safety and low toxicity.

Surgical treatment of the perforated colon with peritonitis.

The authors present their experience on 85 perforations of the colon treated at the Clinic of Surgery, Charles University Hospital in Prague between 1980-1993 and compare them with the results published in the literature. The most frequent cause of perforation was diverticulitis 35, followed by tumorous process 34, artificial injury 10, local ischemic lesion 4 and ulceration 1. All patients with perforation of the colon suffered from peritonitis. The present paper surveys our patients and the causes of perforation. We find it essential to remove the affected part of the colon as the primary surgical approach by performing either a resection combined with primary anastomosis. Hartmann procedure, or resection with terminal colostomy and mucous fistula. However, the optimum therapeutic scheme could only be applied to slightly less than a half of the patients. In the rest, unfavourable conditions, such as poor overall physical state of the patients, extensive local findings, dissemination of the tumours, or extreme progression of the stercoral peritonitis have precluded it. In these particular cases we had to perform colostomy and drainage with significantly poorer results. From the investigation ensues that primary resection of the colon during perforation should be used in all instances where the general condition of the patients, the surgical position and the extent of peritonitis permit.

[Intensive care in patients with intra-abdominal septic complications]. / Intenzívní péce o nemocné s nitrobrisními septickými komplikacemi.

The authors investigated diagnostic and therapeutic possibilities of intensive care units when treating septic conditions in intraabdominal surgery. The authors emphasize the comprehensive and systematic character of the follow up of patients who are threatened by sepsis. Care involves in particular aimed antimicrobial therapy, immunotherapy, normalization of haemodynamics and the acid-base balance and rational parenteral nutrition. Only a thus conceived therapeutic regime makes it possible to control such serious conditions as sepsis.

Absence of cytomegalovirus, Epstein-Barr virus, and papillomavirus DNA from adenoma and adenocarcinoma of the colon.

Biopsy specimens from 13 patients with adenocarcinoma of the colon and from 10 patients with endoscopic polypectomies for colon adenoma were examined for the presence of the DNA of cytomegalovirus (CMV), Epstein-Barr virus (EBV), and human papillomavirus (HPV) types 2, 6, 16 and 18. The specific activities of viral DNA probes obtained by nick--translation ranged from 10(7) to 10(8) cpm/micrograms DNA. By Southern blot hybridization with an estimated sensitivity of 10 pg virus DNA which corresponded to 0.05 virus genome equivalents per cell we failed to detect any virus DNA in the biopsy material tested.

Effect of human recombinant interleukin-2 on cytotoxic response of peripheral blood mononuclear cells in melanoma patients before surgery.

Natural killer activity against K562 targets and recombinant interleukin-2 induced cytotoxicity to NK resistant targets (MEL-4 and T24) was investigated in 15 melanoma patients. Before elective surgery no differences in cytotoxic activities were demonstrated when compared with patients with colorectal adenocarcinoma and controls. No correlation with the depth of the melanoma lesion was observed. Numbers of precursors of IL-2 induced killers in melanoma patients were in normal range. In conclusion, no defects in non-specific NK and IL-2 induced behavior in peripheral blood of melanoma patients were found. Other factors, specific, non-specific, related or unrelated to the tumor side should be thus considered.

[Subtotal thyroidectomy in the treatment of hyperthyroidism]. / Die subtotale Thyreoidektomie bei der Behandlung des Hyperthyreoidismus.

201 cases of hyperthyrotoxic goitre underwent surgery in the period from 1970 to 1977. The importance of team work is emphasized to make reliable decisions concerning indications for surgical or non-surgical treatment. It is stated, that still a considerable controversy remains between Old and New World, concerning both indications for surgical treatment, and extent of surgery in thyreotoxicoses of the G.-B.-typ. The subtotal thyroidectomy represents e reliable method with rapid onset of euthyroidism, advisable in cases in which non-surgical treatment is, from the endocrinological point of view, not recommended, or considered as hazardous.