Haemorrhoidectomy with Ligasure vs conventional excisional techniques: meta-analysis of randomized controlled trials.

OBJECTIVE: To compare the use of LigaSure devices with conventional excisional techniques, circular stapling and use of Harmonic Scalpel in patients with symptomatic haemorrhoids and to review literature on LigaSure technology (Valleylab Inc. USA). METHOD: A literature review was performed using the National Library of Medicine's Pubmed Database using the keywords Ligasure, haemorrhoidectomy, vessel sealing technology. Randomized trials comparing LigaSure with other techniques of excisional haemorrhoidectomy with valid end points were reviewed in the present article and included in a quantitative meta-analysis. RESULTS: There was no significant difference in the proportion of patients cured after Ligasure haemorrhoidectomy or other excisional techniques (P > 0.05). Patients treated with LigaSure had a significantly shorter operative time (P < 0.001), postoperative pain VAS Score (P < 0.001), wound healing time and time-off from work (P < 0.001), than the patients submitted to excisional techniques. Postoperative bleeding did not significantly differ between the two groups (P = 0.056); however, the surgeons observed a reduction of intra- and postoperative bleeding using LigaSure. In comparison to the circular stapler and Harmonic Scalpel the authors found similar postoperative outcomes and a slightly favourable trend for LigaSure regarding postoperative complications, ease of handling and length of the procedure. CONCLUSION: Our meta-analysis shows that Ligasure haemorrhoidectomy is a fast procedure characterized by limited postoperative pain, short hospitalization, fast wound healing and convalescence.

A modification of primary closure for the treatment of pilonidal disease in day-care setting.

AIM: The best surgical technique for treating sacrococcygeal pilonidal disease (PD) is still controversial. We evaluated the outcome of a modified primary closure for the treatment of pilonidal sinus. METHOD: One hundred and fifty-two consecutive patients with PD, who underwent excision and primary closure under local anaesthesia according to our method, participated in this prospective study. The duration of operation and of hospitalization, postoperative pain, time to first mobilization, postoperative complications, time to resumption of work were assessed. RESULTS: The median operative time was 30 min (range: 15-40); the median postoperative pain visual analogue scale score was 1 (range 0-3). All patients were mobilized between 2 and 4 h after surgery and discharged within 10 h. Postoperative complications included eight small debridements of an infected wound (5.3%) and one case of wound dehiscence (0.6%). No recurrence was detected during a median follow-up of 22 months (range: 10-34 months). CONCLUSION: The low complication rate, near total absence of wound dehiscence, the compliance of the patients, the type of anaesthesia and the patient satisfaction makes this method effective. A randomized trial with long-term follow-up is warranted.

Randomized clinical trial of LigaSure and conventional diathermy haemorrhoidectomy.

BACKGROUND: The aim of this randomized prospective trial was to compare LigaSure and conventional diathermy haemorrhoidectomy. METHODS: Two hundred and eighty-four patients with grade III or IV haemorrhoids were randomized to LigaSure or diathermy (Milligan-Morgan) haemorrhoidectomy as a day-case procedure. Operating time, postoperative pain score, hospital stay, postoperative complications, wound healing time and time to return to normal activities were assessed. Thirty-four patients were lost to follow-up. RESULTS: The mean operating time for LigaSure haemorrhoidectomy was significantly shorter than that for diathermy (P = 0.011). Patients treated with LigaSure had significantly less postoperative pain (measured on a visual analogue scale; P = 0.010), a shorter wound healing time (defined as time to absence of swelling; P = 0.012) and less time off work (P = 0.010) than patients who had diathermy. Neither postoperative complications nor mean hospital stay (day-case surgery) were significantly different. CONCLUSION: LigaSure haemorrhoidectomy demonstrates simplicity, reproducibility, a low complication rate, fast wound healing, a quick return to work and reduced postoperative pain.

Parapubic hernia and diabetes insipidus.

According to the current literature parapubic hernia is regarded as a relatively rare pathology. The causative defect is usually related to pelvic surgery, traumatism, or bone malformation. Surgical treatment is difficult, because aponeurotic tissue on which to anchor a mesh on the caudal aspect of the defect is missing. This report describes a case of an incisional pubic hernia related to megabladder in a woman affected by diabetes insipidus and with a past clinical history of multiple pelvic interventions. As far as we are aware this report adds a new pathogenetic issue for parapubic hernias not previously described in the literature.

A camera handler for Miccoli's minimally invasive video-assisted thyroidectomy and paratiroidectomy procedures.

BACKGROUND: Minimally invasive video-assisted thyroidectomy and paratiroidectomy (MIVAT/P) are surgical procedures performed with 5-mm cameras handled by a camera assistant. METHODS: The authors created a new camera handler for video-assisted neck surgery. It consists of a telescopic tripod device designed for mechanical handling of the camera, which is directly oriented by the operator even in solo surgery procedures. The camera is placed inside an O-shaped support, and moved by the operator himself for exploration and work on the surgical field. RESULTS: Thanks to this simple device, the camera holder provides a firm field and prevents blood stains in limited working spaces. CONCLUSIONS: The novel camera handler may be useful in either MIVAT/P or other simple laparoscopic procedures (i.e., cholecystectomy) for a steady handling of the camera, even in solo surgery procedures.

A less invasive, selective, functional neck dissection for papillary thyroid carcinoma.

HYPOTHESIS: To describe an alternative lateral neck access in order to perform neck dissection in papillary thyroid carcinoma (PTC) with lymph node involvement. DESIGN: Prospective (January 2000 to December 2003), 36-month study. SETTING: Catholic University of Rome and University of "Tor Vergata", Rome, Italy. PATIENTS AND METHODS: Twenty-four consecutive patients with PTC and cervical lymph node metastases were included. Functional neck dissection (FND), unilateral or bilateral, was performed acceding via a lateral dissection through a traditional Kocher incision, running along the superficial fascia of the neck and posteriorly to the sternocleidomastoideus muscle. RESULTS: Mean age was 39.04+/-13.69 years. Twenty patients were women and four were men. Mean tumour size was 2.5+/-1 cm, while the greatest metastatic lymph node size was 4.5 cm. Minimally invasive, selective FND was performed in all patients associated to total thyroidectomy and central compartment lymph node clearance. Metastatic lymph nodes were found in 142 out of 340 of the lymph nodes dissected. CONCLUSIONS: Minimally invasive neck dissection seems to carry a lower risk in terms of specific morbidity and allows a quicker recovery and a better aesthetic result. This access has to be considered as a less invasive procedure compared to the other surgical accesses for the radical or modified lateral neck dissection.

Systemic acute-phase response after laparoscopic and open cholecystectomy.

BACKGROUND: Cytokines are the main mediators of inflammation and the response to trauma. The purpose of this study was to compare variations in cytokine levels following laparoscopic cholecystectomy (LC) and mini-laparotomy cholecystectomy (OC), since these two types of operations were considered to be a unique model for examining the role of local tissue injury in postoperative inflammatory reactions. METHODS: A total of 40 patients were studied. Eighteen of them underwent LC; the remaining 22 were operated on using the open technique. Systemic concentrations of interleukin-6 (IL-6), interleukin-1 (IL-1), tumor necrosis factor (TNF), and C-reactive protein (CRP) were measured before and after the operation. In addition, we compared pre- and postoperative white blood cell (WBC) counts, postoperative body temperature, and length of postoperative hospitalization. RESULTS: There was no difference between the two groups in IL-1 and TNF response. The rise in plasma IL-6 levels (18.86 +/- 9.61 vs 5.00 +/- 0.0 pg/ml, p < 0.0001) and CRP (8.40 +/- 5.81 vs 1.43 +/- 1.30 mg/dl, p < 0.001) were more marked after open cholecystectomy than after the laparoscopic procedure. There was no correlation between serum CRP concentrations and the other postoperative parameters. CONCLUSION: The magnitude of the acute-phase response was less pronounced following laparoscopic cholecystectomy, consistent with a reduction in tissue trauma.

Hyperthyroidism with concurrent thyroid cancer.

The occurrence of thyroid malignancy is considered a rare event in hyperthyroid patients. With the aim of assessing the clinical relevance of this association, we have analyzed the incidence of thyroid cancer in hyperthyroid patients treated by surgery. The incidence of thyroid cancer was retrospectively evaluated in 202 hyperthyroid patients who underwent thyroidectomy during a twenty-year period. A thyroid cancer was diagnosed in 12 cases (5.9 per cent). Histologic examination revealed the presence of papillary carcinoma in 9 cases, follicular carcinoma in 1 case and Hürthle cell carcinoma in 2 cases. The association between thyroid cancer and hyperthyroidism was more frequent in toxic adenomas (17.8 per cent) than in toxic diffuse (5.3 per cent) or multinodular goiters (1.7 per cent). In 8 patients they presented as an occult carcinoma (maximum diameter below 1 cm), but unfavourable histologic features, such as local invasiveness and multifocality, were found in 5 of them. Follow-up data indicate that all 12 patients are currently alive and apparently free of disease. Hyperthyroid patients, particularly those affected by toxic adenomas, should be carefully evaluated to exclude the presence of concurrent malignancy. A special attention should be made moreover to the presence of "occult" lesions that, in our study was characterized in a higher proportion (62.5 per cent) of cases, by unfavourable histologic features.

Primary malignant fibrous histiocytoma of the duodenum.

BACKGROUND/AIM: We report on a case of primary malignant fibrous histiocytoma of the duodenum. METHODS: Report of a case and review of the literature on the occurrence of this tumor in the alimentary tract. RESULTS: The neoplasm was detected incidentally at the time of diagnostic workup for upper gastrointestinal bleeding. Curative surgery using the Whipple procedure was carried out with uneventful postoperative course; no evidence of liver metastases was detected during intraoperative ultrasonography. The patient died of diffuse metastatic liver disease 2 months after surgical resection. Up-to-date review of the literature has added only 3 cases to those previously reported, including that reported by us. CONCLUSIONS: The biological behavior of malignat fibrous histiocytomas is extremely aggressive and mainly conditioned by size and histological grading. The treatment of choice, whenever possible, is based on early and complete surgical excision of the tumor.

[Tissue expression of carbohydrate antigen 19-9 (CA 19-9) in adenomatous lesions of the colorectum]. / Espressione tissutale dell'antigene carboidrato 19-9 (CA 19-9) nelle lesioni adenomatose del colon-retto.

Serum levels of tumor markers almost not detectable in precancerous states or early cancer, the behavior of the tumor associated antigen CA 19-9 in colorectal carcinogenesis was analysed. In order to investigate the adenoma-carcinoma sequence, tissue antigenic expression was measured in adenomas, characterized by different size and histology, and compared with that found in normal colonic mucosa. Tissue content of CA 19-9 was determined by an immunoperoxidase technique (ABC-POD) in 88 colonic polyps, and correlated to the degree of histological dysplasia, and dimension of adenoma. Tissue content of CA 19-9 was also evaluated in non-adenomatous mucosa obtained by endoscopic biopsy. Among the 88 polyps, 50 showed the tubular histological type, while 31 resulted tubulovillous and 7 villous. High degree of dysplasia was present in 7 adenomas (7.9%) and focal carcinoma was observed in 6 (6.8%). Positivity for CA 19-9 was registered in 60.2% of adenomas. No correlation was found between tissue-CA 19-9 and degree of dysplasia, size of adenoma and villous component. However, a statistically significant correlation was observed between expression and cellular distribution of the antigen (chi 2 = 98.07, p < 0.00001). Our data confirmed CA 19-9 expression in adenomas, but it is unlikely this tissue antigen proves to be a reliable marker of adenoma-carcinoma sequence.

[Acute biliary pancreatitis]. / Pancreatiti acute biliari.

Biliary pancreatitis is a major complication of gallstones (6-8%) and mainly affects patients with microlithiasis (22%) and cholesterolosis (29%) of the gallbladder. Transient or prolonged obstruction of the ampulla represents the accepted cause and severe forms of acute pancreatitis are more frequently associated with microlithiasis (21.3% vs. 9.6%) with higher incidence of mortality (6.5% vs. 3.2%) as compared with patients with cholelithiasis. The treatment of cholelithiasis and choledocholithiasis performed electively during the same admission, after manifestations of acute pancreatitis had subsided, is an effective procedure to prevent the development of recurrent attacks of pancreatitis. Removal of the gallbladder alone in most patients may represent the definitive treatment, most common bile duct stones passing spontaneously through the papilla during the first four days after admission. Laparoscopic cholecystectomy has gained wide acceptance in the treatment of cholelithiasis, but the management of associated choledocholithiasis results still undefined. Personal strategy is to adopt a more selective approach during the acute attack, limiting the performance of ERCP-ES within the first 48 hours to those patients presenting with laboratory and clinical evidence of ampullary obstruction. If choledocholithiasis is found during laparoscopic cholecystectomy, personal recommendation is to attempt the transcystic removal of stones; if this is not feasible, a conversion of the laparoscopic procedure to an open common bile dut exploration should be carried out. Postoperative ERCP-ES does not seem a reasonably strategy, while preoperative ERCP-ES with gallbladder left in situ as treatment alone of associated biliary tract lesions may be considered in high risk patients. The surgical treatment of pancreatic lesions should be reserved to those patients with extended and unmarked or infected pancreatic necrosis, and pancreatic abscess. Closed management (surgical debridement associated with continuous local lavage of the lesser sac) is recommended, while less frequently ventral open packing should be required.

Acute pseudo-obstruction of the colon (Ogilvie's syndrome): advances in management.

The management of the patients with acute pseudo-obstruction of the colon (APOC) still represents a matter of debate. To better evaluate and compare the effectiveness of various therapeutic approaches in the management of APOC 29 patients were considered. These were included according to three consecutive periods in: group A (1977-1982) concerning patients who underwent medical treatment alone (n = 8) or endoscopic (n = 4) and surgical (n = 1) decompression; group B (1983-1990) in which the management was based on simple endoscopic decompression (n = 10); group C (1991-1995) including patients in whom placement, under fluoroscopic control, of a tube in the cecum following endoscopic decompression was provided (n = 6). Mean time required for resolution of colonic distension was 2.3 (+/- 0.50 SD) days in patients who underwent endoscopic decompression and tube placement, as compared to 4.5 (+/- 2.47 SD) days in the group of patients treated either with conservative measures or simple endoscopic decompression (p = 0.04). No recurrence occurred after colonoscopic decompression and tube placement while colonic distension recurred in 4 of 14 patients managed by simple endoscopic decompression (0% vs. 28.6%, n.s.). Our experience showed that endoscopic decompression is an effective method, moreover if associated with the placement of an indwelling tube into the right colon. This method, for its easiness and safeness, besides its effectiveness in preventing the recurrence of colonic distension, may be surely considered an advance in the management of acute pseudo-obstruction of the colon.

Major acute inflammatory complications of diverticular disease of the colon: planning of surgical management.

BACKGROUND/AIMS: The aim of this study was to determine the most appropriate surgical strategy in the management of patients with major inflammatory complications of colonic diverticular disease. MATERIALS AND METHODS: Out of 259 patients affected by complicated diverticular disease of the colon, 43 consecutive patients (16.6%) who underwent urgent or emergency surgical intervention for diverticular perforation during a 20-year period (1975-1994) were retrospectively analyzed. According to the changes in the surgical approach over the time, the series was divided into two groups: 1975-1985 group A (n = 23), 1986-1994 group B (n = 20). The clinical diagnosis was confirmed by operative and pathologic findings. RESULTS: Out of 43 patients, 11 underwent derivative procedure and 32 resection. There were no significant differences among the two groups of patients according to sex ratio and mean age. The overall percentage of patients in group B who underwent resective procedure (100%) was significantly greater in comparison with that in group A (52%) (p < 0.001). Colostomy and drainage was employed only during the first period (30%)(vs group B, p < 0.05) and the proportion of patients who underwent primary resection and anastomosis was significantly higher during the second period (45%) (vs group A, p < 0.05). CONCLUSIONS: It must be stressed that resection of the diseased segment at initial operation appears mandatory; one-stage procedure is indicated when infection is confined to the mesentery, while resection and anastomosis with covering colostomy (two-stage procedure) is preferable whenever peritoneal contamination has occurred. Hartmann's operation remains the procedure of choice in the patients presenting known impaired immunity or fecal contamination.

Ruptured aneurysm of the superficial femoral artery.

OBJECTIVE: True isolated "arteriosclerotic" aneurysms of the superficial femoral artery are rare. One case of isolated superficial femoral artery aneurysm and review of literature is reported. DESIGN: Case report and review of the literature. SETTING: Hospitalized care. PATIENT: An 80-year old man presenting with rupture of superficial femoral artery aneurysm was observed and treated with graft interposition, which resulted in limb salvage. INTERVENTION: Removal of the aneurysm and replacing of the arterial aneurysmatic segment by interposition of a polytetrafluoroethylene prosthetic graft. MEASURES: Patency of the graft with no evidence of ischemic or embolic complication assessed with a follow-up period of 6 months. RESULTS: From the review of the literature we collected 21 isolated true arteriosclerotic superficial femoral artery aneurysms in 17 patients. These aneurysms may be discovered after the onset of complications such as rupture (33%) or thrombosis and limb ischemia (19%). Other aneurysms are frequently concomitant (69%), mostly represented by abdominal aortic aneurysms (40%). CONCLUSIONS: Ruptured arteriosclerotic aneurysm of the superficial femoral artery is very uncommon and the treatment of choice is based on replacing of the aneurysmal segment with a prosthetic graft interposition or proximal and distal artery ligation and bypass. Early diagnosis and surgical reconstruction is recommended for patients with aneurysms of the superficial femoral artery that are 2.5 cm or greater in maximum diameter and for complicated aneurysms of any size.

Multivariate analysis for predicting the presence of bacteria in bile in patients with acute cholecystitis.

OBJECTIVE: to find out whether the presence of bacteria in bile could be predicted accurately from preoperative data in patients with acute cholecystitis. DESIGN: Prospective open study. SETTING: University hospital. SUBJECTS: 42 patients undergoing cholecystectomy for acute gallstone cholecystitis. MAIN OUTCOME MEASURES: Correlations between 24 preoperative clinical and laboratory variables, and the incidence of pathogenic organism in bile. RESULTS: 4 of the 24 variables tested were of predictive significance. These were external body temperature on admission, percentage of neutrophils, preoperative white blood cell count, and total serum concentration of bilirubin. When these predictive variables were evaluated in the discriminant analysis equation they had a sensitivity of 92% and a specificity of 100% in predicting positive bile culture. CONCLUSION: Multivariate discriminant analysis permits accurate preoperative prediction of bile cultures growing pathogens in patient undergoing cholecystectomy for acute cholecystitis.

[Intraoperative colonoscopy: current indications]. / La colonscopia intraoperatoria: attuali indicazioni.

From January 1987 to December 1991, 37 patients underwent intraoperative colonoscopy for several indications; these latter can be summarized in the need to define the site or extension of the lesions treated or detected by endoscopy before surgery. This procedure is therefore necessary in those cases in whom intraoperative endoscopy is likely to be useful in planning the surgical treatment. The use of intraoperative colonoscopy should be however considered complementary, but not substitutive, of the preoperative colonoscopy.

Wound infection after cholecystectomy. Correlation between bacteria in bile and wound infection after operation on the gallbladder for acute and chronic gallstone disease.

OBJECTIVE: To see if there was a difference in the wound infection rates after operation for acute and chronic cholecystitis, and to see if the presence of bacteria in the bile had any influence on those rates. DESIGN: Prospective open study. SETTING: University hospital. SUBJECTS: 213 Patients undergoing cholecystectomy for acute or chronic gallstone disease. MAIN OUTCOME MEASURES: Incidence of postoperative wound infection, and of bile cultures growing pathogenic organism. RESULTS: There was no difference in wound infection rates between patients operated on for acute and those operated on for chronic cholecystitis. The presence of bacteria in the bile did not seem to influence the wound infection rate in either group. CONCLUSIONS: Early cholecystectomy and appropriate antibiotic prophylaxis result in an acceptably low wound infection rate, and the growth of bacteria from bile is not predictive of the development of wound infection.