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.

Nonerosive gastroesophageal reflux disease and mild degree of esophagitis: comparison of symptoms endoscopic, manometric and pH-metric patterns.

BACKGROUND: Our aim in the present study was to compare patients presenting with gastroesophageal reflux disease in the presence or absence of mild-grade esophagitis (grade I or II according to the Savary-Miller classification). METHODS: Between 2005 and 2007, 215 patients with gastroesophageal reflux disease (67 with reflux associated with grade I or II esophagitis and 148 without esophagitis) were evaluated at the Department of Surgery, University Hospital Tor Vergata, Rome, and were included in the present study. The evaluations consisted of clinical interviews, endoscopy of the high digestive tract, esophageal manometry and pH monitoring. RESULTS: There was no significant difference between the two groups with regard to age, sex or symptoms. The incidence of heartburn associated with noncardiac chest pain was greater in the esophagitis group than in the dysphagia group. The incidence of hiatal hernia was similar in both groups. Although the motor pattern was similar in both groups, the length of the abdominal esophagus was greater in patients without esophagitis (1.6 cm vs 1.1 cm; P < 0.05). The reflux pattern was nearly identical in both groups. CONCLUSIONS: Gastroesophageal reflux without esophagitis must be regarded not as a milder form of the disease but as part of a single disease. Furthermore, these patients often demonstrate lower rates of symptom improvement after antireflux treatment in comparison with patients with erosive esophagitis. Therefore, further trials to assess the treatment algorithm for these patients are warranted.

Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal.

BACKGROUND: Several techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. We conducted a prospective study to assess type of presentation, treatment strategy and outcome over a 5-year period. METHODS: Between 1st January 2005 and 31st March 2011,247 patients presenting with anal fistulas were treated at the University Hospital Tor Vergata and were included in the present prospective study. Mean age was 47 years (range 16-76 years); minimum follow-up period was 6 months (mean 40, range 6-74 months).Patients were treated using 4 operative approaches: fistulotomy, fistulectomy, seton placement and rectal advancement flap. Data analyzed included: age, gender, type of fistula, operative intervention, healing rate, postoperative complications, reinterventions and recurrence. RESULTS: Etiologies of fistulas were cryptoglandular (n = 218), Crohn's disease (n = 26) and Ulcerative Colitis (n = 3). Fistulae were classified as simple -intersphincteric 57 (23%), low transphincteric 28 (11%) and complex -high transphicteric 122 (49%), suprasphincteric 2 (0.8%), extrasphinteric 2 (0.8%), recto-vaginal 7 (2.8%) Crohn 26 (10%) and UC 3 (1.2%).The most common surgical procedure was the placement of seton (62%), usually applied in case of complex fistulae and Crohn's patients.Eighty-five patients (34%) underwent fistulotomy, mainly for intersphincteric and mid/low transphincteric tracts. Crohn's patients were submitted to placement of one or more loose setons.The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%). Three cases of major incontinence (1.3%) were detected during the follow-up period; Furthermore, three patients complained minor incontinence that was successfully treated by biofeedback and permacol injection into the internal anal sphincter. CONCLUSIONS: This prospective audit demonstrates an high proportion of complex anal fistulae treated by seton placement that was the most common surgical technique adopted to treat our patients as a first line. Nevertheless, a good outcome was achieved in the majority of patients with a limited rate of faecal incontinence (6/247 = 2.4%). New technologies provide promising alternatives to traditional methods of management particularly in case of complex fistulas. There is, however, a real need for high-quality randomized control trials to evaluate the different surgical and non surgical treatment options.

Rectal laterally spreading tumors successfully treated in two steps by endoscopic submucosal dissection and endoscopic mucosal resection.

BACKGROUND: Endoscopic submucosal dissection (ESD) is an advanced technique of therapeutic endoscopy alternative to endoscopic mucosal resection (EMR) for superficial gastrointestinal neoplasms >2 cm. ESD allows for the direct dissection of the submucosa and large lesions can be resected en bloc. ESD is not limited by resection size, increases histologically complete resection rates and may reduce the local recurrence. Nevertheless, the technique is time-consuming, technically demanding and associated with a high complication rate. To reduce the risk of complications, different devices and technical advances have been proposed with conflicting results and, still, ESD en bloc resections of huge lesions are associated with increased complications. CASE PRESENTATION: We successfully used a combined ESD/EMR technique for huge rectal laterally spreading tumors (LSTs). ESD was used for circumferential resection of 2/3 of the lesion followed by piecemeal resection (2-3 pieces) of the central part of the tumour. In all three patients we obtained the complete dissection of the polyp and the complete histological evaluation in absence of complications and recurrence at 6 months' follow up. CONCLUSIONS: In the treatment of rectal LSTs, the combined treatment - ESD/EMR resection may be considered a suitable therapeutic option, indicated in selected cases as an alternative to surgery, in which the two techniques are neither reliable nor safe separately. However, to confirm our results, larger trials with longer follow up are required together with improvement of the technique and of the technical devices.

End-to-end versus end-to-side stapled anastomoses after anterior resection for rectal cancer.

BACKGROUND AND AIMS: Sphincter-saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end-to-end and end-to-side anastomosis after anterior resection for T1-T2 rectal cancer. METHODS: During the study period, a total of 298 rectal cancer patients were treated. Patients with T1-T2 rectal cancer (i.e., tumor level < or =15 cm from the anal verge) fit for surgery were asked to participate in the study. Patients were randomized to receive either an end-to-end anastomosis or an end-to-side anastomosis using the left colon. Surgical results and complications were recorded. RESULTS: Seventy-seven patients were randomized. Thirty-seven end-to-end anastomoses and 40 end-to-side anastomoses were performed. Anastomotic leakage after end-to-end anastomosis was 29.2%, while after end-to-side anastomosis was 5% (P = 0.005). In the end-to-end group 11 patients had anastomotic leaks: nine patients needed a re-intervention with colostomy creation subsequently closed in seven cases. Two patients of the end-to-side group experienced anastomotic leakage and were successfully treated conservatively. CONCLUSIONS: Regarding postoperative surgical complications, end-to-side anastomosis is a safe procedure.

Complications and reinterventions after surgery for obstructed defecation.

PURPOSE: Functional results following surgery for obstructed defecation (OD) have been widely investigated, but there are few reports aimed to analyze postoperative complications and re-interventions. This study investigates the adverse events requiring retreatment for obstructed defecation. METHODS: We retrospectively analyzed the records of 203 patients operated on by a single surgeon, 20 transabdominally and 183 transperineally (159 manual and 24 stapled). Postoperative complications requiring retreatment and outcome of reinterventions were analyzed. RESULTS: Adverse events requiring retreatment occurred in 14.3% more frequently after abdominal than after perineal procedures (20% vs. 13.7%), but the sample size of the two arms is different. Rectal bleeding and strictures were the most common adverse events (6.9%). Major complications, i.e., ischemic colitis requiring hemicolectomy and pelvic sepsis requiring colostomy also occurred (1%). The overall reintervention rate was 7.5%, (5% after abdominal and 7.6% after perineal surgery). Overall, 59% of the reoperated patients were still constipated at a median follow up of 2 years. CONCLUSIONS: Complications requiring retreatment are not uncommon after surgery for OD and reinterventions are often unsuccessful. A careful preoperative evaluation and selection of patients should be undertaken in order to minimize adverse events.

Tips and tricks: haemorrhoidectomy with LigaSure.

Haemorrhoidectomy is frequently associated with significant postoperative pain and prolonged hospital stay. New techniques to reduce these problems are constantly under evaluation. Amongst these, LigaSure haemorrhoidectomy is a safe and fast technique that fulfils the requirements of low-complication rate, fast wound healing and quick return to work, reduction in postoperative pain and hospitalisation. The authors detail all the steps of the surgical procedure: operative position; haemorrhoids exposure; dissection, vascular pedicle legation and haemorrhoidal removal, final control. Besides this, the attention is focused on the technical features of LigaSure technology, given that understanding of technical background is a prerequisite for adequate handling of the LigaSure device.

Evaluation of clinical, laboratory and morphologic prognostic factors in colon cancer.

BACKGROUND: The long-term prognosis of patients with colon cancer is dependent on many factors. To investigate the influence of a series of clinical, laboratory and morphological variables on prognosis of colon carcinoma we conducted a retrospective analysis of our data. METHODS: Ninety-two patients with colon cancer, who underwent surgical resection between January 1999 and December 2001, were analyzed. On survival analysis, demographics, clinical, laboratory and pathomorphological parameters were tested for their potential prognostic value. Furthermore, univariate and multivariate analysis of the above mentioned data were performed considering the depth of tumour invasion into the bowel wall as independent variable. RESULTS: On survival analysis we found that depth of tumour invasion (P < 0.001; F-ratio 2.11), type of operation (P < 0.001; F-ratio 3.51) and CT scanning (P < 0.001; F-ratio 5.21) were predictors of survival. Considering the degree of mural invasion as independent variable, on univariate analysis, we observed that mucorrhea, anismus, hematocrit, WBC count, fibrinogen value and CT scanning were significantly related to the degree of mural invasion of the cancer. On the multivariate analysis, fibrinogen value was the most statistically significant variable (P < 0.001) with the highest F-ratio (F-ratio 5.86). Finally, in the present study, the tumour site was significantly related neither to the survival nor to the mural invasion of the tumour. CONCLUSION: The various clinical, laboratory and patho-morphological parameters showed different prognostic value for colon carcinoma. In the future, preoperative prognostic markers will probably gain relevance in order to make a proper choice between surgery, chemotherapy and radiotherapy. Nevertheless, current data do not provide sufficient evidence for preoperative stratification of high and low risk patients. Further assessments in prospective large studies are warranted.

Helicobacter pylori and gastroesophageal reflux disease.

BACKGROUND: The nature of the relationship between Helicobacter pylori and reflux oesophagitis is still not clear. To investigate the correlation between Helicobacter pylori infection and GERD taking into account endoscopic, pH-metric and histopathological data. METHODS: Between January 2001 and January 2003 a prospective study was performed in 146 patients with GERD in order to determine the prevalence of Helicobacter pylori infection at gastric mucosa; further the value of the De Meester score endoscopic, manometric and pH-metric parameters, i.e. reflux episodes, pathological reflux episodes and extent of oesophageal acid exposure, of the patients with and without Helicobacter pylori infection were studied and statistically compared. Finally, univariate analysis of the above mentioned data were performed in order to evaluate the statistical correlation with reflux esophagitis. RESULTS: There were no statistically significant differences between the two groups, HP infected and HP negative patients, regarding age, gender and type of symptoms. There was no statistical difference between the two groups regarding severity of symptoms and manometric parameters. The value of the De Meester score and the ph-metric parameters were similar in both groups. On univariate analysis, we observed that hiatal hernia (p = 0,01), LES size (p = 0,05), oesophageal wave length (p = 0,01) and pathological reflux number (p = 0,05) were significantly related to the presence of reflux oesophagitis. CONCLUSION: Based on these findings, it seems that there is no significant evidence for an important role for H. pylori infection in the development of GERD and erosive esophagitis. Nevertheless, current data do not provide sufficient evidence to define the relationship between HP and GERD. Further assessments in prospective large studies are warranted.

Duplex ultrasound evaluation of testicular perfusion after tension-free inguinal hernia repair: results of a prospective study.

BACKGROUND/AIMS: Open tension-free techniques of hernia repair using synthetic meshes are a well-accepted practice with an excellent patient comfort and a low recurrence rate. Otherwise, the influence of the resulting fibrosis on testicular perfusion is still unclear. In this study, the effect of prosthetic materials on testicular perfusion was evaluated using Duplex ultrasonography. METHODOLOGY: Twenty-four patients participated in this prospective study. A total of 26 procedures were performed under general anaesthesia. All patients underwent standardized scrotal ultrasound study and Duplex imaging preoperatively, 1, 3 and 9 months after the procedure. Scrotal volume, vein diameters and modifications of arterial blood flow, evaluated by the acceleration index (AI), of the funicular and peritesticular vessels were measured. RESULTS: No statistically significant differences were found between preoperative and postoperative measurements which included testicular blood flow parameters and testicular volume. Moreover, in some cases, a testicular flow improvement was detected after the operation. Furthermore the side of the hernia and the position of the mesh slit (lateral or upper) to allow the passage of cord structures did not influence the results. CONCLUSIONS: So far there is no evidence for a significant impairment of funicular structures after open hernia repair using tension free techniques.

Dynamics of liver trauma: tearing of segments III and IV at the level of the hepatic ligament.

The liver is the most commonly injured intra-abdominal organ. Liver mass is the key factor in determining the extent of the inertial force and consequently of damage in the case of sudden deceleration. In this respect, high-speed accidents usually produce characteristic lesions where the III-IV segments tear at the level of the hepatic ligament causing grade I-III liver injuries. The pathophysiology of such traumas is the subject of the present contribution. All trauma patients who sustained a blunt abdominal injury from January 1 to December 31 2004 were identified by the trauma registry at the Policlinico di Tor Vergata In order to select high-speed and sudden deceleration traumas, clinical records were reviewed for demographics, severity of injury, severity of liver injury, associated concomitant injuries, and management scheme. The grade of liver injury was determined on the basis of the initial CT or the intraoperative findings. A total of 159 patients who incurred abdominal injuries due to blunt trauma were identified. In 14 (8.8 percent) one or more liver lesions were associated. Among the low-grade injuries, 3 were grade I, and 8 grade II. Forty percent were high-grade injuries consisting in 6 grade III and 1 grade IV. We observed no grade V or grade VI injuries in this series. The most frequent occurrence was a tear between hepatic segments III and IV caused by the acute impact of the liver on the hepatic ligament. A hepatic injury caused by the round ligament was diagnosed intraoperatively in 1 out of 5 liver trauma patients (20 percent) and preoperatively in 4 out of 5 (80 percent) in our one-year abdominal blunt trauma series. Our clinical contribution underlines the high frequency of such lesions that seems to be related to, and characteristic of, high-speed trauma. In these cases immediate deceleration due to the impact may be a relevant factor in the pathophysiology of the lesion.

Dermoid cyst of the pancreas: presentation and management.

BACKGROUND: Dermoid cyst of the pancreas is a benign, well-differentiated, extremely rare germ cell neoplasm. Published data indicate that differential diagnosis of cystic lesions of the pancreas is challenging and although ultrasonography, computed tomography and magnetic resonance may be useful, radiological findings are often inconclusive and the diagnosis is intraoperative. We report a case of a dermoid cyst of the tail of the pancreas intraoperatively diagnosed and successfully treated with left pancreatectomy. Further, characteristics, preoperative detection and differential diagnosis of this rare pathology are also discussed. CASE PRESENTATION: This report documents the findings of a 64-year-old male presenting with a well defined echogenic pancreatic mass on ultrasonography. Computerized Tomography (CT) showed a 5 cm cystic tumor arising from pancreatic tail and Magnetic Resonance Imaging (MRI) suggested a tumor extension to the middle side of the stomach without defined margins. A left pancreatectomy was performed. On surgical specimen, histological evaluation revealed a dermoid cyst of the tail of the pancreas measuring 8.5 x 3.0 cm. CONCLUSION: Given the benign nature of the dermoid cyst, surgical resection most likely represents the definitive treatment and cure. In addition, resection is indicated in consideration of the difficulty in diagnosing dermoid cyst preoperatively. However, endoscopic ultrasound and fine needle aspiration cytology have recently been shown to be effective, safe, reliable and cost-saving preoperative diagnostic tools. Therefore, until more cases of dermoid cyst are identified to further elucidate its natural history and improve the reliability of the preoperative diagnostic tools, surgical resection should be considered the standard therapy in order to exclude malignancy.

Papillary carcinoma of the gallbladder and anomalous pancreatico-biliary junction. Report of three cases and review of the literature.

BACKGROUND/AIMS: Papillary carcinoma of the gallbladder is less invasive, less frequently metastasizes and results in a longer survival than other gallbladder tumors. It is frequently associated with Anomalous Pancreatico-biliary junction (APBJ), a malformation that occurs most frequently in Japan. Consequently, most cases of papillary cancer have been reported in the Japanese literature, while the incidence of this neoplasm, and its association with APBJ, is still unknown in Western Countries. METHODOLOGY: Seventy cases of gallbladder cancer, observed between January 1992 and December 2000, were retrospectively evaluated. All the histological sections and available cholangiograms were reviewed. RESULTS: Three cases of papillary carcinoma were found (4.2%); APBJ was detected in one of these. All patients underwent resection and are long-term survivors; one patient developed, three years later, a papillary cancer of the common bile duct and was treated by Whipple's procedure. CONCLUSIONS: This study provides evidence that papillary carcinoma is more rare in Western countries than in Japan and it is characterized by a longterm survival after surgical resection. Further studies and reports are necessaries to define if this different incidence can justify differences between Western and Japanese results after surgery for gallbladder cancer.

Treating chronic anal fissure with botulinum neurotoxin.

Recent reports confirm that the management of chronic anal fissure has undergone extensive re-evaluation during the past few years. This rejuvenation of interest is attributable to the application of neurochemical treatment, which has contributed to the tendency to treat the disease on an outpatient basis. The use of botulinum neurotoxin seems to be a promising and safe approach for the treatment of chronic anal fissure, particularly in patients at high risk for incontinence. Indeed, botulinum neurotoxin has been successfully used selectively to weaken the internal anal sphincter as a treatment for chronic anal fissure. It is also more efficacious than nitrate therapy, and is not related to the patient's willingness to complete treatment.