Anorectal diseases in patients with Antiphospholipid syndrome: a cross-sectional study.

BACKGROUND: Hemorrhoid disease (HD) is one of the most common gastrointestinal complaints worldwide, affecting 4.4% of the general population in the United States. Since antiphospholipid syndrome (APS) may lead to intra-abdominal thrombosis, one may expect that this condition can impact the risk for HD development. Additionally, as APS patients are more prone to thrombosis and treatment with anticoagulants may increase risk of bleeding, one may also infer that rates of HD complications may be higher in this scenario. Nevertheless, no data in these regards have been published until now. The objective of the present study is to evaluate frequency of HD and describe its complications rates in antiphospholipid syndrome APS patients. METHODS: We consecutively invited patients who fulfilled APS criteria to undergo proctological examination. After examination, patients were divided in two groups, based on the presence of HD, and compared regarding different clinical manifestations and antiphospholipid profile. We performed the analysis of the data, using chi-square and Mann Whitney U when applicable and considering a significance level of 0.05. Multivariate regression analysis included age and variables with p < 0.10 in the bivariate analysis. RESULTS: Forty-one APS patients agreed to undergo proctological examination. All were female and overall median age was 43 (36-49). Seventeen (41.4%) patients were diagnosed with HD, with the following frequency distribution: 7 internal (41.2%), 4 external (23.5%) and 5 mixed hemorrhoids (29.4%). Of the internal hemorrhoids, 5 patients were classified as grade I (71.4%), 1 grade II (14.3%), and 1 grade IV (14.3%). Prior gestation (p = 0.067) and constipation (p = 0.067) correlated with a higher frequency of HD. In multivariate analysis, constipation remained as an important risk factor (OR 3.92,CI95% 1.03-14.2,p = 0.037). Five out of 17 patients (29.4%) reported anal bleeding, but it did not correlate with warfarin dose (p = 0.949). Surgical treatment was indicated for 10 patients (58.8%). Other anorectal findings were anal fissure, plicoma, condyloma and one chlamydial retitis. CONCLUSION: We found an unexpected high frequency of hemorrhoids in APS patients, with a great proportion requiring surgical treatment.

Anorectal diseases in patients with Antiphospholipid syndrome: a cross-sectional study

Abstract Background: Hemorrhoid disease (HD) is one of the most common gastrointestinal complaints worldwide, affecting 4.4% of the general population in the United States. Since antiphospholipid syndrome (APS) may lead to intra-abdominal thrombosis, one may expect that this condition can impact the risk for HD development. Additionally, as APS patients are more prone to thrombosis and treatment with anticoagulants may increase risk of bleeding, one may also infer that rates of HD complications may be higher in this scenario. Nevertheless, no data in these regards have been published until now. The objective of the present study is to evaluate frequency of HD and describe its complications rates in antiphospholipid syndrome APS patients. Methods: We consecutively invited patients who fulfilled APS criteria to undergo proctological examination. After examination, patients were divided in two groups, based on the presence of HD, and compared regarding different clinical manifestations and antiphospholipid profile. We performed the analysis of the data, using chi-square and Mann Whitney U when applicable and considering a significance level of 0.05. Multivariate regression analysis included age and variables with p < 0.10 in the bivariate analysis. Results: Forty-one APS patients agreed to undergo proctological examination. All were female and overall median age was 43 (36-49). Seventeen (41.4%) patients were diagnosed with HD, with the following frequency distribution: 7 internal (41.2%), 4 external (23.5%) and 5 mixed hemorrhoids (29.4%). Of the internal hemorrhoids, 5 patients were classified as grade I (71.4%), 1 grade II (14.3%), and 1 grade IV (14.3%). Prior gestation ( p = 0.067) and constipation ( p = 0.067) correlated with a higher frequency of HD. In multivariate analysis, constipation remained as an important risk factor (OR 3.92,CI95% 1.03-14.2, p = 0.037). Five out of 17 patients (29.4%) reported anal bleeding, but it did not correlate with warfarin dose ( p = 0.949). Surgical treatment was indicated for 10 patients (58.8%). Other anorectal findings were anal fissure, plicoma, condyloma and one chlamydial retitis. Conclusion: We found an unexpected high frequency of hemorrhoids in APS patients, with a great proportion requiring surgical treatment.(AU)

Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial.

BACKGROUND: Rubber band ligation (RBL) is probably the most commonly performed nonsurgical therapy for hemorrhoidal disease. Infrared coagulation (IRC) is one of the most recent advances based on the use of "heat". Recent studies have demonstrated similar efficacy for both modalities. This prospective randomized crossover trial compared IRC and RBL for pain, complications, effectiveness, and patient satisfaction and preference in the treatment of internal hemorrhoids (IH). METHODS: Patients were randomized to receive either RBL (Group A) or IRC (Group B) for treatment of the first hemorrhoid; in a second procedure two weeks later, patients underwent the other procedure on the second hemorrhoid, thereby serving as their own control. The procedure preferred by the patient was employed two weeks later for the third hemorrhoid. Post-treatment pain was evaluated on a visual analog scale and on the basis of the percentage of patients requiring analgesics. Bleeding and early outcome of treatment were also recorded, together with the patient's satisfaction. RESULTS: A total of 94 patients were included in this study (47 patients in each group). At 30 minutes and 6 hours after treatment, pain scores were significantly higher in patients treated with RBL than in those treated with IRC (p<0.01). There was no significant difference in pain scores between the two procedures immediately and 24 hours after the procedures (p<0.05). After 72 hours and one week, the pain scores for RBL and IRC were similar. The percentage of patients using analgesics was significantly higher in RBL group than in IRC group at 6 hours (29.6% vs. 19.2%, respectively; p<0.05) and 24 hours (22.5% vs. 13.5%, respectively; p<0.05) after treatment. However, significant differences were not noted at 72 hours (12.7% vs. 6.4%; p<0.05) and one week (5.6% vs. 7.1%; p>0.05) after the procedures. There were significantly higher incidences of bleeding immediately, 6 hours, and 24 hours after RBL compared to IRC (immediate: 32.4% vs. 4.3%; 6 hours: 13.4% vs. 3.6%, 24 hours: 26.8% vs. 10.2%, respectively; p<0.01). However, there were no significant differences noted regarding the incidence of bleeding between the two groups at 72 hours. Complications were more likely after RBL than IRC, however this difference was not significant (p>0.05). Overall, 91 patients (96.8%) were successfully treated and 93 patients (99%) were very satisfied with the treatment. In the third treatment session, 50% of patients selected RBL and 50% chose IRC. CONCLUSIONS: Both RBL and IRC were well-accepted and highly efficacious methods for the treatment of IH; in addition, both procedures were associated with relatively minor complications. However, RBL was associated with more pain than IRC in the 24-hour postoperative period.

Surgical treatment of haemorrhoidal disease with CO2 laser and Milligan-Morgan cold scalpel technique.

OBJECTIVE: To prospectively compare immediate postoperative results of the surgical treatment of haemorrhoidal disease (HD) by Milligan-Morgan technique using either the CO(2) laser or cold scalpel. METHODS: Forty patients with grade III/IV HD were prospectively randomized to undergo surgical treatment (Milligan-Morgan) using either the CO(2) laser (group A) or the cold scalpel method (group B). Data were compared regarding postoperative pain, complications, healing time, return to normal activity and patient satisfaction. Patients were blinded to treatment method until the completion of the study. Postoperative outcomes were assessed by patient questionnaire and outpatient follow-up visits. Pain was assessed by Visual Analogue Scale and analgesic consumption. RESULTS: Twenty patients were randomized into each group and were comparable relative to mean age, gender and grade of HD. There were no statistically significant differences regarding postoperative pain measured (P =0.17) or consumption of oral (P = 0.741) and parenteral analgesics (P = 0.18) between the two groups. Mean pain score at the first bowel movement was significantly higher in group A (P = 0.035), although the use of analgesics was similar in both the groups. There were no differences regarding complications, mean healing time, return to normal activities and patient satisfaction. CONCLUSION: There were no differences in the immediate results after Milligan-Morgan haemorrhoidectomy using either the CO(2) laser or cold scalpel regarding postoperative pain, complications, healing time, return to normal activities or patient satisfaction.

Radiation-induced total regression of a highly recurrent giant perianal condyloma: report of case.

We report a case of a highly recurrent giant perianal condyloma, or Buschke-Lowenstein tumor, which was successfully treated by telecobalt therapy. We conclude that radiation therapy is an optional treatment modality for the management of giant perianal condylomata in selected cases.

Rectal neovagina: Simonsen's technique for large rectovaginal fistula repair.

Rectovaginal fistulas are difficult to manage and cause significant morbidity. A new technique for large rectovaginal fistula repair is presented; it is based on the creation of a neovagina associated with an established abdominal pull-through operation. This technique has been used since 1970 in selected cases, with very little morbidity and no operative mortality.

[Muscle-aponeurotic transposition for treatment of anal incontinence]. / Transposições músculo-aponevróticas utilizadas para o tratamento da incontinência anal grave.

The management of anal incontinence varies. It can be treated either clinically or surgically depending on its etiology and the intensity of the signs and symptoms. The variety of procedures and techniques employed in its treatment is proof of the incomprehension of the pathophysiological mechanisms involved as well as their diversity. Sphincteroplasties are indicated for those patients with well-defined muscle injury, usually resulting from obstetrical trauma, iatrogenic surgery or vehicular accidents. In cases of persistent anal incontinence after previous sphincteroplasty or those in which extensive destruction of the sphincteric musculature is confirmed, muscle-aponeurotic transpositions are an attractive option. A detailed survey of the literature of the chief techniques utilized and their results is presented.

[Ambulatory anorectal surgery under local anesthesia: analysis of 351 procedures]. / Cirurgia proctológica ambulatorial sob anestesia local: análise de 351 operações.

Three hundred and twenty-eight patients with anorectal diseases were submitted ambulatory surgery, under local anesthesia, in a three-year period. Three hundred and fifty one operations were performed in outpatient service. Local anesthesia by Hook-Needle Puncture technique was used in 37 operations and the rest of them by classical technique through infiltration of both lateral anal quadrants. Hemorrhoids, fistulas, fissures and pilonidal cysts were the most frequent diseases treated (71.6%). The incidence of early and late complications was 19.6% and 4.8%, respectively. The most common complication was severe pain (16.1%). Five patients (1.5%) required hospitalization due postoperative complications. The surgery on an outpatient basis was a well-accepted procedure for two hundred eighty-eight patients (88%). The main benefit reported by patients was the possibility of recovery at home, which is more comfortable. The ambulatory anorectal surgery under local anesthesia is a safe and effective method, with the additional advantage of the costs saved and increase of available beds for more complex surgery.

[Transsacral rectopexy for treatment of bleeding rectal prolapse in a patient with severe liver disease: case report]. / Retopexia transacral para o tratamento de procidência retal sangrante em paciente hepatopata grave: relato de caso.

Rectal procidentia is an uncommon but debilitating condition that often affects elderly patients with significant medical problems. Fecal incontinence is usually frequent. Abdominal rectopexy with or without sigmoid resection repeatedly demonstrate lower recurrence rates (2-4%) but in high-risk patients, morbidity and mortality may be significant. Perineal or transacral approaches may be used in these patients to avoid the complications of abdominal procedures and general anesthesia. The lack of experience with transacral approach has limited your utilization by colon and rectal surgeons. We describe a case of rectal procidentia in patient with severe liver disease (Child C) sucssefull treated with transacral rectopexy, detailing the technique used.

[True splenic cyst treated with++videolaparoscopy. Case report and review of the literature]. / Cisto esplênico verdadeiro tratado por videolaparoscopia. Relato de caso e revisão da literatura.

True non-parasitic splenic cysts are uncommon, their real incidence is difficult to determine since over 30% are asymptomatic. Preoperatively these cysts are rarely diagnosed correctly and they are often findings on examinations. Partial or total splenectomy is the treatment of choice after ruling out splenic hydatidosis, since it is responsible for two thirds of global incidence. Currently, with the technological advances of surgery, especially of videolaparoscopy, some authors have proposed its use for partial cystectomy or splenectomy. The authors present the case of a true splenic cyst (epidermoid) which was resected videolaparoscopically and they discuss aspects of diagnosis and management.

Hook-needle puncture. A new technique of local anesthesia for anorectal surgery.

PURPOSE: Anorectal surgery has been increasingly performed as an ambulatory procedure using general, regional, and local anesthesia. Local anesthesia is classically performed through infiltration of four quadrants around the anal verge, which renders the procedure painful and uncomfortable for most surgeons and patients. We present a new, painless technique of local anesthesia for anorectal surgery. METHODS: Patients with surgical risk Classes I and II (American Society of Anesthesiologists) bearing anorectal pathologies were sedated and placed on the operating table in the prone jackknife position. After local antisepsis, the anal canal was lubricated with 2 percent lidocaine gel, and the mucosa was punctured by a hook-shaped, curved, 22-gauge needle just above the pectinate line. A solution of local anesthetics was slowly infused in all four quadrants to the submucosal level. If needed, more anesthetics were infused during the operation. RESULTS: This technique was easily and painlessly applied in more than 60 patients and permitted execution of several ambulatory anorectal procedures with comfort and safety. CONCLUSIONS: The hook-needle puncture for local anesthesia is an effective and safe procedure and may be routinely used for ambulatory anorectal surgery in selected patients.

Retrorectal tumors complicating pregnancy. Report of two cases.

PURPOSE: Retrorectal tumors are rare entities often found in females during reproductive age. Reports of retrorectal tumors complicating pregnancy are scant. This study presents two cases of retrorectal tumors complicating pregnancy and a literature review. METHODS: Two patients bearing retrorectal tumors diagnosed during pregnancy were referred to our care at the postpartum period. Both then underwent exploratory laparotomy. RESULTS: One patient had premature delivery by cesarean section because of hemorrhage from abruptio placentae followed by fetal mortality. Attempts to resect the tumor immediately after delivery had been unfruitful. The tumor was also unresectable on exploratory laparotomy. Biopsy studies of the tumor were consistent with low-grade myosarcoma. Another patient had a benign cystic mass that had been conservatively monitored throughout pregnancy. A healthy baby was delivered at term by cesarean section. The cyst was later resected via Kraske's incision and was diagnosed as cystic teratoma. CONCLUSIONS: Retrorectal tumors may cause significant local effects such as complicated pregnancy. Early detection in the population at risk is needed, as correct diagnosis and treatment may be done only on surgical exploration. During pregnancy, careful monitoring of advanced tumors is mandatory and may be sufficient to prevent maternal and fetal complications.

[Freeman-Sheldon syndrome: generalized muscular rigidity after anesthetic induction]. / Síndrome de Freeman-Sheldon: rigidez muscular generalizada tras inducción anestésica.

We describe a case of generalized muscle rigidity in a 2-year-old patient with Freeman-Sheldon syndrome undergoing surgery for eventration of the diaphragm after anesthetic induction with halothane and succinylcholine. Anesthetic induction was by mask with oxygen, nitrous oxide and halothane, with succinylcholine as a muscle relaxant. Approximately 10 minutes after start of induction, muscular rigidity appeared and developed rapidly, becoming severe and compromising ventilation. Tracheal intubation was attempted without success, owing to stiffness of the masseter muscles. Sodium dantrolene 2.5 mg/kg was administered and relaxation was achieved immediately for both masseter and peripheral muscles, such that the patient recovered spontaneous breathing. We conclude that there is risk of association between Freeman-Sheldon syndrome and malignant hyperthermia.

[Mediastinoscopy: apropos of 100 cases]. / Mediastinoscopia: a propósito de 100 casos.

We have retrospectively reviewed 100 mediastinoscopies that were carried out in our hospital from 1985 to 1988. 12% the of patients had relative contraindications for that examination technique. There was no intraoperative mortality and 5% of the patients presented complications including severe hemorrhage in three patients, bilateral pneumothorax in one patient and loss of radial pulse in another patient who presented left hemiparesis during the immediate postoperative period. We conclude that mediastinoscopy provides essential information for classification and treatment of lung cancer despite its high potential morbidity; a proper anesthetic technique, correct monitoring and the close cooperation with the surgical team render mediastinoscopy a safe procedure.