Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal.

BACKGROUND: The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years. METHODS: Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment. RESULTS: Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications. CONCLUSIONS: Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.

Role of 0.4% glyceryl trinitrate ointment after haemorrhoidectomy: results of a prospective randomised study.

INTRODUCTION: Conventional haemorrhoidectomy (CH) is well known to cause significant post-operative pain and delayed return to daily activities. Both surgical wounds and sphincterial apparatus spasms are likely responsible for the pain. In this study, we evaluated the role of glyceryl trinitrate ointment (GTN) in reducing post-operative pain, ameliorating wound healing and recovery after CH. PATIENTS AND METHODS: Between 01/08 and 12/11, 203 patients with symptomatic haemorrhoids were enrolled in the study and received (103 patients) or not (100 patients) 0.4 % GTN ointment for 6 weeks after surgery. Pain was assessed using a 10-cm linear visual analogue scale (VAS). Data on post-operative pain, wound secretion and bleeding, return to normal activities and complications were recorded. Data were analysed using Fisher's exact and Mann-Whitney tests. RESULTS: GTN-treated group experienced significantly less pain during the first week after surgery (p < 0.0001). This difference was more evident starting from post-operative day 4 (p < 0.0001). A significant higher percentage of untreated patients experienced severe pain (mean VAS score > 7) (10 % vs 31 %). There were significant differences in terms of secretion time (p = 0.0052) and bleeding time (p = 0.02) in favor of GTN. In addition, the duration of itching was less in the GTN group (p = 0.0145). Patients treated with GTN were able to an early return to daily activities compared to untreated (p < 0.0001). Fifteen GTN-treated patients (14.6 %) discontinued the application because of local discomfort and headache. CONCLUSIONS: GTN ointment enhances significantly post-operative recovery, reducing pain in terms of duration and intensity. This effect might be secondary to a faster wound healing expressed by reduced secretion, bleeding and itching time.

2-Methoxy-5-amino-N-hydroxybenzamide, a derivative of mesalamine, inhibits colon cancer cell growth through cyclo-oxygenase-2-dependent and -independent mechanisms.

COX-2 (cyclo-oxygenase-2) and PGE2 (prostaglandin E2) play a key role in sustaining CRC (colorectal cancer) cell growth and survival. Indeed, the use of agents targeting the COX-2/PGE2 axis has been associated with a reduction in the development of CRC in both humans and murine models of colon carcinogenesis. In the present study, we investigated whether 2-methoxy-5-amino-N-hydroxybenzamide (herein termed 2-14), a derivative of mesalamine that inhibits CRC cell growth both in vitro and in vivo, negatively regulates COX-2/PGE2 expression in CRC cells and assessed whether the 2-14-mediated anti-neoplastic effect is strictly dependent on the inhibition of this pathway. Our results show that 2-14 blocks the growth and enhances the death of HT-115, a CRC cell line overexpressing COX-2, and that these effects associate with inhibition of COX-2 but not COX-1. 2-14 also down-regulates TNFα (tumour necrosis factor α)-induced COX-2 in HT-29 cells as well as COX-2/PGE2 expression in ex vivo cultures of human CRC explants. Similarly, 2-14 reduces COX-2, but not COX-1, in tumoural areas developing in a mouse model of CAC (colitis-associated colon cancer). Finally, we show that 2-14 exhibits in vitro and in vivo anti-mitogenic effects in DLD-1, a COX-deficient CRC cell line. Taken together, these results suggest that 2-14 inhibits CRC cell growth through COX-2-dependent and -independent mechanisms.

Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial.

BACKGROUND: The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. The purpose of this study was to compare prospectively and randomly three different techniques of SLR during LSG. METHODS: From April 2010 to April 2011, patients submitted to LSG were randomly selected for the following three different techniques of SLR: oversewing (group A); buttressed transection with a polyglycolide acid and trimethylene carbonate (group B); and staple-line roofing with a gelatin fibrin matrix (group C). Primary endpoints were reinforcement operative time, incidence of postoperative staple-line bleeding, and leaks. Operative time was calculated as follows: oversewing time in group A; positioning of polyglycolide acid and trimethylene carbonate over the stapler in group B; and roofing of the entire staple line in group C. RESULTS: A total of 120 patients were enrolled in the study (82 women and 38 men). Mean age was 44.6 ± 9.2 (range, 28-64) years. Mean preoperative body mass index was 47.2 ± 6.6 (range, 40-66) kg/m². Mean time for SLR was longer in group A (14.2 ± 4.2 (range, 8-18) minutes) compared with group B (2.4 ± 1.8 (range, 1-4) minutes) and group C (4.4 ± 1.6 (range, 3-6) minutes; P < 0.01). Four major complications were observed (3.3 %): one leak and one bleeding in group A; one bleeding in group B; and one leak in group C, with no significant differences between the groups. No mortality was observed. CONCLUSIONS: SLR with either polyglycolide acid with trimethylene carbonate or gelatin fibrin matrix is faster compared with oversewing. No significant differences were observed regarding postoperative staple-line complications.

Radiofrequency versus ultrasonic energy in laparoscopic colorectal surgery: a metaanalysis of operative time and blood loss.

BACKGROUND: Various energy sources are available for tissue dissection and vessel sealing in laparoscopic colorectal surgery. The electrothermal bipolar vessel sealing system (EBVS) and ultrasonic energy (UE) devices are widely used to provide hemostatic dissection in laparoscopic procedures. Nevertheless, available evidenced-based data comparing their operative results still are scarce. This study conducted a metaanalysis of controlled clinical trials comparing EBVS and UE in terms of operative time and intraoperative blood losses in laparoscopic colorectal surgery. METHODS: The MEDLINE and Embase databases were searched using medical subject headings and free text words. All randomized controlled trials (RCTs) and controlled clinical trials using EBVS and UE in laparoscopic colorectal surgery were considered for inclusion in the study. Random effects models were used in case of heterogeneity to obtain summary statistics for the overall difference in operating time and blood loss between instruments. RESULTS: Four studies comparing EBVS with UE for 397 patients (200 EBVS vs. 197 UE patients) were included in the study. The findings showed that EBVS was associated with a significantly shorter operative time and less intraoperative blood loss than UE (p < 0.05). CONCLUSIONS: The metaanalysis indicated that EBVS is associated with a shorter operative time and less blood loss than UE in laparoscopic colorectal surgery. However, these results should be interpreted with caution due to the high heterogeneity of the included trials and the limited number of studies with a high level of evidence. More adequately designed RCTs with a larger number of patients are required to confirm the results of this metaanalysis.

Porcine dermal collagen matrix injection may enhance flap repair surgery for complex anal fistula.

INTRODUCTION: The use of biomaterials to treat anal fistula has drawn great interest. More recently, a porcine dermal matrix injection has been proposed as infill biomaterial to treat fistulas. METHODS: We propose a novel approach consisting in non-cutting seton positioning followed by flap repair associated with dermal matrix injection into the fistula tracts after several weeks. RESULTS: We report our experience with this two-staged procedure on 11 consecutive patients with recurrent high trans-sphincteric fistulas with a minimum follow-up of 6 months. CONCLUSIONS: In our experience, this two-stage approach seems to be safe and effective.

Metachronous splenic metastasis from colonic carcinoma five years after surgery: a case report and literature review.

Metastatic lesions of the spleen are a rare finding and are generally associated with widespread disease. Moreover, solitary metastases of the spleen are exceptional. In this paper, we describe the case of a patient who developed an isolated splenic metastasis from colon carcinoma five years after surgery, and was successfully treated by splenectomy. We also review the scant literature experience discussing clinical diagnosis and approaches to this uncommon event.

Iatrogenic rectal perforation during operative colonoscopy: closure with endoluminal clips.

The risk of perforation during diagnostic or operative colonoscopy can be as high as 2%. Despite conservative treatment being acceptable, the closure of the perforation is usually mandatory, and surgery (either open or laparoscopic) is commonly advocated as rescue therapy. Currently, with the availability of the Endoclip, endoscopists are able to manage iatrogenic perforations avoiding surgery. Clip placement, if necessary, will not delay surgery and might help the surgeon find the site of perforation. However, data in the literature are scant, especially for the closure of large colonic defects. Endoscopic repair using Endoclip devices for a large high rectal perforation following polypectomy is described herein.

Laparoscopic reoperative approach after open bariatric surgery.

The aim of the study was to evaluate the laparoscopic approach to reoperative bariatric surgery. From January 2003 to July 2007, 26 obesity surgery patients were referred to our Institution for revision. Nineteen patients previously had an open gastric banding, 3 an open vertical banded gastroplasty, 2 an open jejunoileal by-pass (J-l BP) and 2 an open gastric by-pass. Indications for re-operation were insufficient weight loss in 14 patients, band slippage in 7, band erosion in 3 and severe malabsorptive syndrome in 2. Mean preoperative BMI was 45 kg/m2. Twenty-six laparoscopic re-operative procedures were performed. Three patients required a third operation. Eleven gastric banding patients underwent band removal, 7 gastric banding patients were converted to an open gastric by-pass, 1 band was removed and simultaneously re-placed, the 2 jejuno-ileal by-pass patients underwent an intestinal restoration, 3 vertical banded gastroplasty patients were converted to laparoscopic gastric by-pass, 1 open gastric by-pass patient was converted to a laparoscopic long-limb gastric by-pass and in 1 patient with a gastro-gastric fistula after open gastric by-pass the fistula was resected. Further procedures included 1 laparoscopic gastric banding, 1 laparoscopic gastric bypass and 1 laparoscopic bilio-pancreatic diversion. Conversion to laparotomy was needed in 5 cases (5/29, 17.2%). Early complications included 1 case of pneumothorax and 6 cases of wound infection (24.1%). Mortality was zero. The mean follow-up was 36.2 months. Mean postoperative BMI was 34.3 kg/m2. Laparoscopic reoperative bariatric surgery is feasible, safe and effective after open bariatric surgery.

Laparoscopic versus open ileo-colonic resection in Crohn's disease: short- and long-term results from a prospective longitudinal study.

Possible relations between surgical approaches, frequency, and severity of Crohn's disease recurrence after ileo-colonic resection is unknown. We aimed to assess perioperative outcomes and postsurgical complications of laparoscopic versus standard open surgery and to detect differences between the two groups in endoscopical recurrence and patients' satisfaction. Twenty-eight consecutive patients undergoing elective ileo-colonic resection by either laparoscopic approach (n = 15) or conventional open surgery (n = 13) were prospectively enrolled. No mortality or major intraoperative complications were observed in both groups. Significant differences between groups were the median operating time found shorter in the open group than in the laparoscopic group (p = 0.003), the higher dosage of pain killers needed in the open group (p = 0.05), the passage of flatus and\or stool after surgery found faster in group A (p = 0.004) and the shorter recovery period in the laparoscopic group (p = 0.007). Colonoscopy was performed in 27 patients. The frequency and pattern of recurrence did not differ between the two groups (p = 0.63). Patients' satisfaction was significantly in favor of laparoscopy. Present findings support the feasibility and advantages in the short-term of laparoscopic ileo-colonic resection in patients with Crohn's disease. No differences were observed in terms of frequency, time of onset, and severity of recurrence in a 1-year follow-up.

Early (1 hour) post-operative parathyroid hormone (PTH) measurement predicts hypocalcaemia after thyroidectomy: a prospective case-control single-institution study.

The aim of the study was to evaluate the efficacy of parathyroid hormone 1-hour assay for the early prediction of hypoparathyroidism after thyroidectomy. Candidates for total, subtotal, completion thyroidectomy or lobectomy were entered into the study. Pre- and postoperative calcium and parathyroid hormone (1 hour and postoperative day 1 after thyroidectomy) levels and clinical hypocalcaemia were recorded. Patients were divided into 3 groups and 2 subgroups: 1. patients who underwent lobectomy (control group); 2. patients who underwent total thyroidectomy with postoperative hypocalcaemia (2A: asymptomatic patients, 2B: symptomatic patients); 3. asymptomatic patients with normal calcium levels after total thyroidectomy. Of 119 patients, 109 underwent total thyroidectomy and 10 lobectomy. Of the 109 patients submitted to total thyroidectomy, 35 (32.11%) developed postoperative transient hypocalcaemia. Twenty-one patients (19.27%) were asymptomatic and 14 (12.84%) were symptomatic. Parathyroid hormone levels decreased after 1 hour in group 3 (32.98 pg/dl), 2A (9.84 pg/dl) and 2B (7.46 pg/dl). There was no significant difference in parathyroid hormone levels at 1 hour between group 2A and 2B (p = 0.06), but were significantly lower compared to groups 3 and 1 (p < 0.05). Parathyroid hormone levels at 1 hour after total thyroidectomy is a good predictor of early hypocalcaemia. It might be more useful than serum calcium monitoring for the early identification of patients requiring postoperative calcium supplementation.

Medical and surgical treatment of chronic anal fissure: a prospective study.

The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF). From 1/04 to 09/06, 156 patients with typical CAF completed the study. All patients were treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 8 weeks, patient was assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral internal sphincterotomy (LIS). During the follow-up (19 +/- 8 months), healing rates, symptoms, incontinence scores, and therapy adverse effects were prospectively recorded. Overall healing rates were 65.3 and 96.3% after GTN/DIL or BTX/LIS. Healing rate after GTN or DIL were 39.8 and 46%, respectively. Thirty-six patients (23.1%) responded to further medical therapy. Fifty-four patients (34.6%) underwent BTX or LIS. Healing rate after BTX was 81.8%. LIS group showed a 100% healing rate with no morbidity and postoperative incontinence. In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence.

Integrated Approaches for the Management of Staple Line Leaks following Sleeve Gastrectomy.

Introduction. Aim of the study was trying to draw a final flow chart for the management of gastric leaks after laparoscopic sleeve gastrectomy, based on the review of our cases over 10 years' experience. Material and Methods. We retrospectively reviewed all patients who underwent LSG as a primary operation at the Bariatric Unit of Tor Vergata University Hospital in Rome from 2007 to 2015. Results. Patients included in the study were 418. There were 6 staple line leaks (1.44%). All patients with diagnosis of a leak were initially discharged home in good clinical conditions and then returned to A&E because of the complication. The mean interval between surgery and readmission for leak was 13,4 days (range 6-34 days, SD ± 11.85). We recorded one death (16.67%) due to sepsis. The remaining five cases were successfully treated with a mean healing time of the gastric leak of 55,5 days (range 26-83 days; SD ± 25.44). Conclusion. Choosing the proper treatment depends on clinical stability and on the presence or not of collected abscess. Our treatment protocol showed being associated with low complication rate and minor discomfort to the patients, reducing the need for more invasive procedures.

Corrigendum: Correction of the First Author's Affiliation. Outcome of Colorectal Surgery in Elderly Populations.

[This corrects the article on p. 139 in vol. 32, PMID: 27626024.].

Gender Influence on Long-Term Weight Loss and Comorbidities After Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: a Prospective Study With a 5-Year Follow-up.

BACKGROUND: Gender might be important in predicting outcomes after bariatric surgery. The aim of the study was to investigate the influence of gender on long-term weight loss and comorbidity improvement after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: A cohort of 304 consecutive patients underwent surgery in 2006-2009: 162 (98 women, 64 men) underwent LSG and 142 (112 women, 30 men) underwent LRYGB. The mean follow-up time was 75.8 ± 8.4 months (range, 60-96 months). RESULTS: Overall mean (95% CI) reduction in BMI was 23.5 (24.3-22.7) kg/m(2) after 5 years, with no statistical difference between LSG and LRYGB groups (P = 0.94). The overall means ± standard deviations of %EBMIL after 5 years were 78.8 ± 23.5 and 81.6 ± 21.4 in the LSG and LRYGB groups, respectively. Only for LSG group %EBMIL after 24-36 and 60 months differed significantly between male and female patients (P = 0.003 versus P = 0.06 in LRYGB), and 89 versus 90% of patients showed improvements in comorbidities in the LSG and LRYGB groups, respectively. Only two patients (women) were lost to follow-up: 1/162 (0.6%) for LSG at the 4th year and 1/142 (0.7%) for LRYGB to the 5th year. CONCLUSIONS: LSG was more effective in obese male than in female patients in terms of %EBMIL, with no difference in comorbidities. LRYGB elicited similar results in both genders in terms of %EBMIL and comorbidities.

Erratum: Author Name Correction: Outcome of Colorectal Surgery in Elderly Populations.

[This corrects the article on p. 139 in vol. 32, PMID: 27626024.].

Outcome of Colorectal Surgery in Elderly Populations.

PURPOSE: The aim of this study is to investigate the impact of age on short-term outcomes after colorectal surgery in terms of the 30-day postoperative morbidity and mortality rates. METHODS: The subjects for the study were patients who had undergone colorectal surgery. Patients were divided into 2 groups according to age; groups A and B patients were ≥80 and <80 years old of age, respectively. Both groups were manually matched for body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index and procedure performed. RESULTS: A total of 200 patients, 91 men (45.5%) and 109 women (54.5%), were included in this retrospective study. These patients were equally divided into 2 groups. The mean ages were 85 years in group A (range, 80 to 104 years) and 55.3 years in group B (range, 13 to 79 years). The overall 30-day postoperative mortality rate was 1% of total 200 patients; both of these 2 patients were in group A. However, this observation had no statistical significance. No intraoperative complications were encountered in either group. The overall 30-day postoperative morbidity rate was 27% (54 of 200) for both groups. The 30-day postoperative morbidity rates in groups A and B were 28% (28 of 100) and 26% (26 of 100), respectively. However, these differences between the groups had no statistical significance importance. CONCLUSION: Age alone should not be considered to be more of a contraindication or a worse predictor than other factors for the outcome after colorectal surgery on elderly patients.

Laparoscopic treatment of Bouveret's syndrome presenting as acute pancreatitis.

Gastric outlet obstruction as a result of gallstone (Bouveret's syndrome) is a rare but serious complication of cholelithiasis. Although patients present with persistent vomiting, colicky epigastric pain and dehydration, the clinical features of the Bouveret's syndrome are not pathognomonic. Due to its rarity, the diagnosis and treatment represent a challenge for the surgeon. In most of the reported cases, the diagnosis was made at the time of laparotomy. We report an unusual clinical presentation of Bouveret's syndrome with mild acute pancreatitis that was treated laparoscopically. To our knowledge, this is the first described case. Cause, clinical presentation, methods of diagnosis, and options for management of Bouveret's syndrome are also discussed.

[Interdisciplinary use of a Day Surgery unit]. / La Day-Surgery interdivisionale ed interdisciplinare. Aspetti organizzativi ed economici.

BACKGROUND: A Day Surgery unit can be defined as a service dedicated to those patients which are not eligible for a simple ambulatory treatment, though requiring a short hospital stay for less than 12 hours. The Italian regulation for Day Surgery has been developed in the last 80's. Three models have been defined: 1) Autonomous unit; 2) Mono o multidisciplinary units: 3) Dedicated beds. Admission criteria are clinical data, age, familial support. METHODS: The Tor Vergata University Hospital has an autonomous multidisciplinary Day Surgery unit, opened on November 22, 2002. Cost and clinical data are independently calculated and stored, allowing as to evaluate the activity of the first 14 months of its life (Nov 02-Dec 03). RESULTS: 5288 patients have been treated, with a preliminary access for lab and clinical evaluation, a surgical procedure and postoperative controls. The Author have calculate that treating as in patients would have needed a dept of 40 beds. CONCLUSIONS: DS offers both 1) economics, and 2) social advantages: 1) lower cost for patients admission. highes. Rate of turn-over, reduction of human resources (no overnight cost), finally, rational use of the NHS funds. 2) Prompt and better response to pts needs and requests; more hospital beds dedicated to emergency and severe cases; reduction of cost for pts and relative quicker return to work; favourable psychological approach for the pts.