Adrenal-sparing surgery: current concepts on a theme from the past.

Adrenal insufficiency represents a debilitating condition which mandates lifelong steroid replacement and which is associated with significant long-term morbidity, due to either inadequate or excessive replacement. The concept of preserving healthy cortical tissue by means of partial adrenalectomy has evolved as a means of avoiding the detrimental consequences of adrenal insufficiency. The advent of advanced technology in adrenal surgery has greatly facilitated the performance of partial adrenalectomy, enabling utilization of this method in an increasing number of endocrine diseases. Hereditary pheochromocytoma, Conn's syndrome, Cushing's syndrome, and non-functional adrenal masses represent the current indications for partial adrenalectomy, although the specific circumstances under which adrenal-sparing surgery should be proposed are still debatable. Partial adrenalectomy can be achieved by all types of minimally invasive surgery. In the absence of randomized, prospective, controlled studies designed to compare laparoscopic, retroperitoneoscopic, and robot-assisted partial adrenalectomy, none of these techniques has as yet been proven to be the gold standard for adrenal-sparing surgery. Apart from indications for surgery, results of surgery, and different types of partial adrenalectomy, controversial topics addressed in this review article include technical aspects such as the volume of residual adrenal tissue needed, ligation of adrenal vein, and means of tumor identification. Discussion of these controversial topics represents an attempt to define the role of partial adrenalectomy in modern adrenal surgery.

Paving the way for changing perceptions in breast surgery: a systematic literature review focused on oncological and aesthetic outcomes of oncoplastic surgery for breast cancer.

BACKGROUND: The emphasis on aesthetic outcomes and quality of life after breast cancer surgery has motivated breast surgeons to develop oncoplastic breast conserving surgery (OPS). Training programs are still rare in most countries, and there is little standardization, which challenges the scientific evaluation of these techniques. This systematic review aims to assess oncological and cosmetic outcomes of OPS. METHODS: After a strict selection process with precise inclusion and exclusion criteria, oncologic and aesthetic outcomes of oncoplastic surgery were searched, using the MEDLINE database up to September 30th, 2017. Available published literature was classified in levels of evidence. After a thorough screening process, only studies with the best level of evidence were included on selection. Systematic reviews and meta-analyses were not included for methodological reasons. RESULTS: Titles and abstracts of 2.854 citations were identified and after screening 15 prospective studies including 1.391 patients were reviewed and scored in detail. Local relapse was found in 2.8% of cases with a wide range of follow-up (from 6 to 74 months). Close margins were retrieved in 11% of cases and positive margins in 9.4% of cases. Mastectomy was implemented in 6.9% of breast cancer patients to whom OPS was performed. Good cosmetic outcomes were detected in 90.2% of patients undergoing OPS, leaving open issues for who should perform cosmetic evaluation and which method should be used. CONCLUSION: Tumor margins, mastectomy rates, and cosmetic outcomes of OPS have to be further improved by standardizing various aspects of OPS. Research efforts should focus on level I evidence assessing both oncological and aesthetic outcomes of OPS and survival rates.

The effect of erythropoietin on uterus inflammation during ischemia reperfusion injury in rats.

OBJECTIVE: This experiment evaluated the influence of erythropoietin (Epo) in an animal model of uterine ischemia reperfusion using the quoting established protocol. DESIGN: The effects of erythropoietin treatment were evaluated by mean uterus inflammation (UI) lesions. UI lesions were determined at the 60th reperfusion min (for groups A and C) and at the 120th reperfusion min (for groups B and D). Groups A and B received no drugs, whereas rats from groups C and D were administered with erythropoietin. METHODS: 40 rats of mean mass 247.7 g were employed for the study. RESULTS: Epo administration non-significantly decreased the UI scores [without lesions] by 0.1 [-0.6244129 - 0.4244129] (p = 0.6294)). Reperfusion time kept non-significantly increased the UI scores by [without lesions] 0.15 [-0.60230385 - 0.50230385] (p = 0.5782). Together, Epo administration combined with reperfusion time non-significantly decreased the UI scores by [without lesions] 0.0727273 [-0.3886782 - 0.2432236] (p = 0.6439). CONCLUSIONS: Epo administration whether it interacted or not with reperfusion time non-significantly short-term decreased the UI lesions scores. Perhaps, a longer study time than two hours or a higher Epo dose may provide more significant effects.

Preliminary Results of the Influence of Duodenojejunal Bypass in a Porcine Model of Streptozotocin-Induced Diabetes Mellitus.

BACKGROUND: Type 2 diabetic obese patients present with a normalization of plasma glucose levels shortly after most bariatric procedures, before any significant weight loss takes place. There is only scarce literature in the new field of metabolic surgery, with most experiments being performed on small animal models. AIM: Our aim is to develop a reliable large animal model for assessment of surgical correction of diabetes. METHOD: Titrated doses of streptozotocin (STZ) were used for induction of diabetes mellitus. After standardization of the surgical technique to avoid any restrictive component, three groups were created, a duodenojejunal bypass (DJB; n = 4), a gastroileal conduit (GIC; n = 3) near the ileocecal valve, and a sham (control; n = 5) group. Preoperative and postoperative glycemic curves were recorded by means of intravenous glucose tolerance tests. Body weight fluctuations were recorded as well. RESULTS: Diabetes was successfully induced with the use of STZ in all cases. Animals in the sham group remained diabetic for 3 weeks after operation. There was normalization of blood glucose levels in the operative groups during the 3-week postoperative follow-up, without significant body weight changes. The duodenojejunal group resulted in stronger positive response of glycemia. CONCLUSION: STZ-induced diabetes in swine leads to a reliable large animal model for assessment of metabolic surgical procedures. STZ is an effective but highly toxic means for inducing stable diabetes in the sensitive porcine model. Duodenojejunal bypass, although less invasive, seems to exert better antidiabetic effects than gastroileal conduit.

The acute effect of the antioxidant drug "U-74389G" on mean platelet volume levels during hypoxia reoxygenation injury in rats.

BACKGROUND: This experimental study examined the effect of the antioxidant drug "U-74389G", on a rat model and particularly in a hypoxia - reoxygenation protocol. The effects of that molecule were studied hematologically using blood mean platelets volume (MPV) levels. METHODS: 40 rats of mean weight 231.875 g were used in the study. MPV levels were measured at 60 min of reoxygenation (groups A and C) and at 120 min of reoxygenation (groups B and D). The drug U-74389G was administered only in groups C and D. RESULTS: U-74389G administration kept significantly increased the predicted MPV levels by 12.77 ± 3.07% (p = 0.0001). Reoxygenation time non-significantly decreased the predicted MPV levels by 2.55 ± 3.71% (p = 0.4103). However, U-74389G administration and reoxygenation time together kept significantly increased the predicted MPV levels by 7.09 ± 1.91% (p = 0.0005). CONCLUSIONS: U-74389G administration whether it interacted or not with reoxygenation time kept significantly increased the predicted MPV levels. This finding has great clinical interest in blood clotting and coagulation pathophysiology.

[The Effect of the Antioxidant Drug U-74389G on Magnesium Levels During Hypoxia-Reoxygenation Injury in Rats].

OBJECTIVE: The aim of this experimental study was to examine the effect of the antioxidant drug U-74389G in a rat model of hypoxia-reoxygenation using the previously established protocol. Effects of treatments were evaluated by magnesium (Mg2+) levels in blood. METHODS: Non-randomized controlled study was performed. Mg2+ levels were determined in 60 min (groups A and C) and 120 min (groups B and D) after starting the reoxygenation. Groups A and B received no drugs, whereas rats from groups C and D were administered with U-74389G. RESULTS: 40 rats 16-18 weeks old of a mean weight of 2312 g were employed in the study. It is demonstrated that U-74389G administration did not alter the Mg2+ levels (decrease in Mg2+ concentration was 0.28±2.75%; p=0.917). Reoxygenation non-significantly increased the Mg2+ levels by 4.27±2.66% (p=0.107). Together, the U-74389G administration and reoxygenation non-significantly increased the Mg2+ levels by 0.36±1.64% (p=0.823). CONCLUSION: U-74389G administration, alone or in concert with reoxygenation did not significantly affect Mg2+ level in blood after experimental hypoxia in rats.

Single-Incision Laparoscopic Right Hemi-Colectomy: a Systematic Review.

As surgeons became more adept with laparoscopic colon surgery, other less invasive procedures, such as single-incision laparoscopic right hemi-colectomy (SIL-RH), have been applied. The objective of this study was to evaluate the safety of SIL-RH as well as its intraoperative and postoperative outcomes for right-sided colon diseases. A detailed search in PubMed for citations that included SIL-RH from 2000 to 2014 revealed 21 studies fulfilling the criteria of the present review. A total of 684 patients were analyzed. Of the patients, 50.2 % were men. Mean patient age was 64.8 years. Of the patients, 36.1 % had already undergone an abdominal operation before the performance of SIL-RH, while 69 % of the patients underwent SIL-RH for colon cancer. Relatively low rates of overall morbidity (15 %) and mortality (0.75 %) were reported in the included studies. Mean length of postoperative hospital stay (LOS) was 5.5 days. Bowel motility return had a mean value of 2.8 days. Mean number of harvested lymph nodes (LN) was 19.2 LN. All resection margins were tumor-free. SIL-RH was a safe alternative to multiport laparoscopic right hemi-colectomy (ML-RH) in terms of morbidity and mortality, postoperative gastrointestinal function recovery, LOS, as well as oncological radicalness.

High serum CA 19-9 but not tumor size should select patients for staging laparoscopy in radiological resectable pancreas head and peri-ampullary cancer.

BACKGROUND: The objective of this study was to validate current recommendations for the selective use of staging laparoscopy in patients with radiological resectable pancreas head and peri-ampullary tumors. METHODS: Data from a prospectively collected database (2007-2013) of 136 patients with peri-pancreatic head cancer were analyzed. RESULTS: Over a 6 year time period, 136 patients were evaluated, 126 patients were deemed radiological resectable and underwent laparotomy and 10 patients were characterized radiological unresectable. There were 111 patients with pancreas head resection and 15 without resection (8 due to extensive vascular involvement and 3 due to peritoneal/liver metastases). The sensitivity, specificity, PPV and NPV of pre-operative radiological imaging in determining unresectability due to liver/peritoneal metastases were 42%, 100%, 100% and 94.7% respectively. There was a significant difference in CA 19-9 values between metastatic and non-metastatic disease (p = 0.020). ROC curve analysis calculated the optimal CA 19-9 cutoff point for predicting metastasis at 215.37 U/ml with a sensitivity of 72.7%, a specificity of 58.3%, PPV of 15.1% and NPV of 95.5%. Tumor diameter was not a significant factor in predicting resectability. Laparoscopy would have been useful in only 5.3% of patients in the present series. CONCLUSION: High CA 19-9 values (>215 U/ml) and not tumor size should select patients with radiological resectable peri-pancreatic cancer for staging laparoscopy.

Differentiation of BIRADS-4 small breast lesions via Multimodal Ultrasound Tomography.

PURPOSE: To demonstrate the use of a new 3D diagnostic imaging technology, termed Multimodal Ultrasonic Tomography (MUT), for the detection of solid breast lesions < 15 mm in maximum dimension. METHODS AND MATERIALS: 3D MUT imaging was performed on 71 volunteers presenting BIRADS-4 nodules, asymmetrical densities, and architectural distortions in X-ray mammograms, who subsequently underwent biopsy. MUT involved D tomographic imaging of the pendulant breast in a water bath using transmission ultrasound and constructed multimodal images corresponding to refractivity and frequency-dependent attenuation (calibrated relative to water). The multimodal images were fused into composite images and a composite index (CI) was calculated and used for diagnostic purposes. The composite images were evaluated against results of histopathology on biopsy specimens. RESULTS: Histopathology revealed 22 malignant and 49 benign lesions. The pixels of 22 malignant lesions exhibited high values in both refractivity and attenuation, resulting in CI values > 1. In contrast, 99.9% of benign lesions and normal tissue pixels exhibited lower values of at least one of the attributes measured, corresponding to CI values < 1. CONCLUSIONS: MUT imaging appears to differentiate small malignant solid breast lesions as exhibiting CI values >1, while benign lesions or normal breast tissues exhibit CI values <1. KEY POINTS: • MUT was able to detect all 22 biopsy-confirmed malignant lesions. • MUT was able to differentiate the malignant from the benign lesions. • Additional MUT detections outside the biopsy area must be evaluated prospectively.

VEGF and Id-1 in pancreatic adenocarcinoma: prognostic significance and impact on angiogenesis.

OBJECTIVES: The significance of vascular endothelial growth factor (VEGF) and inhibitor of differentiation/DNA synthesis (Id-1) in tumor neoangiogenesis and tumor progression in pancreatic ductal adenocarcinoma (PDAC) is still unclear. Given the central role of VEGF in cancer angiogenesis and the inconclusive results on Id-1 expression in PDAC, it is of great interest to investigate whether Id-1 and VEGF expression are associated with angiogenesis and prognosis in PDAC. METHODS: Paraffin-embedded specimens from 60 consecutive patients with PDAC were immunostained for VEGF, Id-1 and CD34 and staining quantification was assessed by Image analysis system. The correlations among the expression of individual angiogenic factors and microvessel density (MVD), clinicopathologic features and clinical prognosis were analyzed. RESULTS: Id-1 and VEGF Positive Activity Indices (PAIs) closely correlated with each other. MVD positively correlated with both Id-1 and VEGF expression. More advanced T and N status correlated with more intense expression of Id-1, VEGF and higher MVD. With regard to prognostic significance higher Id-1 PAI (adjusted HR = 1.69, 95%CI: 1.10-2.59, p = 0.017), higher VEGF PAI (adjusted HR = 2.66, 95%CI: 1.09-6.50, p = 0.032), and MVD (adjusted HR = 1.55, 95%CI: 1.27-1.88, p < 0.001) were associated with poorer survival. CONCLUSIONS: VEGF and Id-1 overexpression were found to be associated with high MVD and emerged as adverse prognostic factors in terms of patient survival in PDAC. The potential of selective anti-angiogenic targeting therapy for pancreatic malignancies should prompt further validation of the present findings in studies encompassing larger samples and more elaborate techniques.

Estimation of maspin's subcellular localization in invasive ductal breast cancer via light microscopy and computerized image analysis: a comparative study.

PURPOSE: Contradictory results have been reported concerning the role of maspin and its cellular distribution in breast cancer. The purpose of this study was to examine the subcellular localization (nuclear-cytoplasmic) of maspin in breast cancer and to compare the evaluation of maspin immunostaining via light microscopy (LM) to the estimation via computerized image analysis (CIA) system. We also examined correlations between maspin expression and several clinicopathological parameters. METHODS: The sample consisted of 48 primary invasive ductal carcinomas (IDC) of the breast. Maspin immunostaining was quantified and graded via LM by two pathologists, separately in the nuclear and cytoplasmic compartments. Total maspin expression was also estimated via CIA system. Univariate non-parametric statistics and stepwise multivariate ordinal logistic regression were performed. RESULTS: Both maspin components (nuclear and cytoplasmic) were closely associated with each other (p<0.001). Total maspin score was positively and closely associated with nuclear maspin (p<0.001) and cytoplasmic maspin (p<0.001). Total maspin , nuclear maspin and cytoplasmic maspin did not correlate significantly with either age, grade, T, N and M status, stage, micro vessel density (MVD) (CD34), ki-67, p53, estrogen receptor (ER) and HER-2 status, or with any of the 4 groups of the molecular classification. The only factor that showed a borderline inverse correlation with nuclear maspin (p=0.059) was progesterone receptors (PR) positivity. CONCLUSION: The cytoplasmic and nuclear fractions of maspin seem to be closely interwoven. Evidently, both mutually intertwined counterparts were independently reflected upon the total maspin levels measured by CIA. Future studies should ideally encompass all three approaches (nuclear, cytoplasmic, total) adopted herein.

Aromatase inhibitors with or without gonadotropin-releasing hormone analogue in metastatic male breast cancer: a case series.

BACKGROUND: Data regarding the safety and effectiveness of aromatase inhibitors (AIs) as monotherapy or combined with gonadotropin-releasing hormone (GnRH) analogue in male breast cancer are scarce. METHODS: In this retrospective chart review, cases of male breast cancer patients treated with AIs with or without a GnRH analogue were evaluated. RESULTS: Twenty-three men were included into this case series. Aromatase inhibitors in combination with or without a GnRH analogue were given as first-line therapy in 60.9% and as second-line therapy in 39.1% of patients, respectively. All patients had visceral metastases, whereas in five of them bone lesions coexisted. In all cases AIs were tolerated well, and no case of grade 3 and 4 adverse events was reported. A partial response was observed in 26.1% of patients and stable disease in 56.5%. Median overall survival (OS) was 39 months and median progression-free survival (PFS) was 13 months. Regarding OS and PFS, no significant effects of GnRH analogue co-administration or type of AI were noted. CONCLUSION: Our study shows that AIs with or without GnRH analogues may represent an effective and safe treatment option for hormone-receptor positive, pretreated, metastatic, male breast cancer patients.

A cost-utility analysis of laparoscopic vs open treatment of colorectal cancer in a public hospital of the Greek National Health System.

PURPOSE: Laparoscopic colectomy has been reported as a safe and oncologically similar operation to open colectomy. A number of expensive surgical instruments are necessary for the procedure which should be applied if it is cost-effective for the patient and the health system in general. The purpose of the current study was the economic evaluation of laparoscopic compared to open colectomy for the treatment of colon cancer in the Greek national health system. METHODS: Fifty patients undergoing open colectomy and 42 undergoing laparoscopic colectomy were enrolled in this case-control study. Length of hospital stay, duration of operation, complication rates, cost of equipment used, total costs and three questionnaires measuring quality of life /QoL (EQ-5D, SF-36 and QLQ-C30) at baseline, 1 and 3 months after the operation were recorded. RESULTS: No statistically significant difference in QoL measured by QALYs between laparoscopic and open colectomy was observed. On the other hand, cost utility analysis revealed that laparoscopic colectomy was more expensive considering the advantages it offers. CONCLUSIONS: Laparoscopic colectomy is not superior to open colectomy on a QoL basis in the Greek public hospital system and is less cost-effective compared to the open procedure. Since the expensive equipment used in laparoscopic colectomy seems to be the causative factor for the high cost of this type of operation, an effort should be made to reduce it either by using reusable instruments or by implementing policies aiming at suppliers cutting down equipment charges.

Post-colectomy assessment of gastrointestinal function: a prospective study on colorectal cancer patients.

BACKGROUND: Anatomical changes after intestinal resection and the effects of adjuvant treatment for colorectal cancer may lead to gastrointestinal disturbances. The aim of our study was to assess gastrointestinal function using validated health-related quality of life (HRQoL) questionnaires that are able to reliably quantify patients' symptoms. METHODS: Two hundred and eighty-nine colorectal cancer patients underwent HRQoL assessment preoperatively and at 3,6 and 12 months postoperatively. They were evaluated with the Gastrointestinal Quality of Life Index (GIQLI) ["global" and "symptoms" scales and questions 3 ("bloating"), 4 ("excessive gas"), 6 ("gurgling noises"), 7 ("frequent bowel movements (BMs)"), 30 ("urgent BMs"), 31 ("diarrhea"), 32 ("constipation"), 36 ("uncontrolled stools")] and the European Organization for Research and Treatment of Cancer (EORTC) modules QLQ-C30 (symptom scales: "constipation" and "diarrhea") and QLQ-CR29 (symptom scales: "defecation problems," "incontinence," and "bloating"). RESULTS: GIQLI "global" and "symptom" indices and the majority of single-item scores and the EORTC QLQ-C30 "constipation" and "diarrhea" subscales showed significant postoperative improvement (p < 0.05). Females and younger age (<70 years) patients appeared to have worse postoperative gastrointestinal function. Rectal cancer patients had more "urgent BMs," "uncontrolled stools" and worse "global" and "symptom" scores at 3 months and more "diarrhea" at 3 and 6 months than colon cancer patients (p < 0.03). Right colectomy patients had less "excessive passage of gas," "constipation," and "uncontrolled stools" than left colectomy patients (3 months, p < 0.01). Anterior resection patients faced more gastrointestinal difficulties, especially in the first 6 months after surgery. Adverse effects related to stage and adjuvant treatment were predominant only at baseline (p < 0.05). GIQLI "diarrhea" and "constipation" scores were correlated with the respective EORTC QLQ-C30 domains (p = 0.0001). CONCLUSIONS: Overall, gastrointestinal function is improved after colorectal cancer surgery. However, women and younger patients are at higher risk of postoperative gastrointestinal dysfunction.

Novel technology of multimodal ultrasound tomography detects breast lesions.

OBJECTIVES: To introduce a new three-dimensional (3D) diagnostic imaging technology, termed "multimodal ultrasonic tomography" (MUT), for the detection of breast cancer without ionising radiation or compression. METHODS: MUT performs 3D tomography of the pendulant breast in a water-bath using transmission ultrasound in a fixed-coordinate system. Specialised electronic hardware and signal processing algorithms are used to construct multimodal images for each coronal slice, corresponding to measurements of refractivity and frequency-dependent attenuation and dispersion. In-plane pixel size is 0.25 mm × 0.25 mm and the inter-slice interval can vary from 1 to 4 mm, depending on clinical requirements. MUT imaging was performed on 25 patients ("off-label" use for research purposes only), presenting lesions with sizes >10 mm. Histopathology of biopsy samples, obtained from all patients, were used to evaluate the MUT outcomes. RESULTS: All lesions (21 malignant and four benign) were clearly identified on the MUT images and correctly classified into benign and malignant based on their respective multimodal information. Malignant lesions generally exhibited higher values of refractivity and frequency-dependent attenuation and dispersion. CONCLUSION: Initial clinical results confirmed the ability of MUT to detect and differentiate all suspicious lesions with sizes >10 mm discernible in mammograms of 25 female patients.

Prospective evaluation of health-related quality of life after laparoscopic colectomy for cancer.

BACKGROUND: The aim of the present study was to prospectively determine health-related quality of life (HRQoL) changes and affecting factors after elective laparoscopic colectomy for cancer. METHODS: The SF-36, EORTC QLQ-C30 and QLQ-CR29, and Gastrointestinal Quality of life Index (GIQLI) were used to assess 85 patients preoperatively and at 1, 3, 6, and 12 months. RESULTS: An initial drop form baseline values was observed in 3 of 8 SF-36 domains, 3 of 5 QLQ-C30 functional scales and 1 of 5 GIQLI subscales. Emotional functioning (EF) was better postoperatively even from the first month (p = 0.03). Most functional domains were improved compared to baseline. The statistically significant changes (p < 0.05) were in the SF-36: general health (GH) (3 months), physical function (PF) (12 months) and role limitations due to emotional problems (12 months); in the QLQ-C30: EF (12 months); in the GIQLI: the global score and PF at 12 months and EF (3, 6, 12 months). From the first month after surgery, most QLQ-C30 "symptom" items were better than baseline. QLQ-CR29 "anxiety" and the "defecation problems" scales were significantly better than baseline at 1, 12 and at 6, 12 months (p < 0.05). Advanced stage (III) and chemotherapy were linked to worse EF, social function (SF), GH and global quality of life (QOL) at 3 and 6 months (p < 0.01). Males appeared to have a worse HRQoL than females at 3 and 6 months, and in 5 of 8 SF-36 domains and 3 of 5 GIQLI subscales at 12 months (p < 0.05). According to the QLQ-CR29, rectal surgery was associated more often with "impotence," "stoma problems" and "incontinence" up to 6 months, and ostomies with "embarrassment" and "stoma problems" (p < 0.05). CONCLUSIONS: HRQoL generally improved over the first year after laparoscopic colectomy reaching even better levels than before surgery. There was an early postoperative improvement in patients' emotional status. The main factors affecting HRQoL seem to be tumor stage, chemotherapy and male sex.

Genomic instability in ulcerative colitis: a prerequisite for cancer in the inflammatory colon?

Ulcerative colitis (UC), a chronic and relapsing idiopathic inflammatory disease of the colon, although not associated with an increased mortality compared to the general population, has a substantial morbidity leading to sizable health care costs, as it carries an increased risk for development of colorectal cancer (CRC). The pathophysiology behind this carcinogenic pathway is multifactorial. This review summarizes the major pathogenetic steps from which the inflamed colonic epithelium is transformed to a dysplastic and/or cancerous one. The role of the inflammatory and immune system, the oxidative stress generated as well as the genomic stability observed in UC-associated CRC is presented so as to provide a more spherical view of the tumorigenic process and, if possible, offer new diagnostic approaches for the early detection of CRC.

Rectoanal repair versus suture haemorrhoidopexy: a comparative study on suture mucopexy procedures for high-grade haemorrhoids.

BACKGROUND: The isolated application of Doppler-guided haemorrhoidal artery ligation (DGHAL) may fail due to the increased reprolapse rate for high-grade haemorrhoids. DGHAL has been combined with a proctoscopic-assisted transanal rectal mucopexy of the prolapsing tissue. The technique is called rectoanal repair (RAR) and is an evolution of various mucopexy and suture haemorrhoidopexy (SHP) techniques. A prominent external component may require minimal (muco-) cutaneous excision (MMCE) of protruding anoderm or minor cutaneous excision of skin tags. METHODS: Fifty-seven patients with symptomatic Goligher grade III and IV haemorrhoids underwent DGHAL followed by either RAR or SHP. In 26 cases, the addition of MMCE was necessary. RESULTS: No significant differences were observed between the two approaches with regards to pain scores measured with visual analogue scale (VAS). On postoperative day 1, mean pain score at rest was 5.81 (±2.23 SD) after SHP versus 5.08 (±2.35 SD) after RAR, while mean pain score at first defecation was 7.31 (±1.6 SD) versus 7.52 (±1.83 SD). There was no difference in the duration of analgesic requirements, postoperative complications and residual prolapse between the 2 procedures. The addition of MMCE did not affect postoperative pain nor analgesic requirements. With the exception of 8 patients who still had with skin tags or minimal protrusion, the remaining of patients (86 %) were asymptomatic and recurrence-free at an average follow-up of 20 months. Overall, 94.8 % of patients stated that they were satisfied with the results, and 91.2 % that they would repeat it if necessary. CONCLUSIONS: Performance of either SHP or RAR after DGHAL is a safe and effective surgical tactic for advanced grade haemorrhoids. Our initial results do not confirm any superiority of RAR over traditional SHP.