Does a more extensive mucosal excision prevent haemorrhoidal recurrence after stapled haemorrhoidopexy? Long-term outcome of a randomized controlled trial.

AIM: The study aimed in a multicentric randomized controlled trial to define the role of a more extensive mucosal resection on recurrence of mucosal prolapse in patients with Stage III haemorrhoids undergoing stapled haemorrhoidopexy. METHOD: In all, 135 patients were randomized to treatment with a PPH-01/03 (Ethicon EndoSurgery) or an EEA (Covidien) stapler. They were reviewed after a minimum follow-up of 4 years to determine the rate of recurrent mucosal prolapse and general condition (wellness evaluation score). Postoperative bowel dysfunction was assessed using the Rome III criteria. RESULTS: Eighty-seven (65%) of the 135 patients (48 in the EEA stapler group and 37 in the PPH group) were available for long-term follow-up. The two groups were comparable for age, gender and duration of follow-up (mean 49.3 ± 5.4 months and 49.0 ± 5.3 months respectively). In the EEA group, 11 (23%) patients had some degree of recurrent prolapse compared with 12 (32%) in the PPH group (P = 0.409). Persistence of anal bleeding was significantly higher in the PPH group (P = 0.04) while the postoperative Haemorrhoid Symptom Score was significantly better in the EEA group (1.73 ± 1.65 vs 3.17 ± 1.94, P < 0.001). The wellness evaluation score was significantly better in the EEA group (1.2 ± 1.27 vs 0.6 ± 1.0, P = 0.028). Furthermore, 7 (15%) of the patients in the EEA group complained of some evacuation disturbance compared with 13 (36%) in the PPH group (P = 0.021). CONCLUSION: The study failed to demonstrate any significant difference in the long-term recurrence rate of Stage III haemorrhoids using EEA or PPH. Nevertheless, use of the larger volume EEA provides better symptom resolution compared with PPH.

Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR).

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Safety and short-term effectiveness of EEA stapler vs PPH stapler in the treatment of degree III haemorrhoids: prospective randomized controlled trial.

AIM: Stapled haemorrhoidopexy has gained wide acceptance due to less postoperative pain although postoperative bleeding and prolapse recurrence are among the major drawbacks of this technique compared with the standard Milligan-Morgan hemorrhoidectomy. The aim was to investigate a new stapler device designed to overcome these side effects. METHOD: In all, 135 patients (71 men, mean age 42 years) with degree III haemorrhoids were randomly allotted to stapled haemorrhoidopexy with PPH® staplers (Ethicon EndoSurgery) (63 patients) or with an EEA® stapler (Covidien) (72 patients) in four referral colorectal centres. The number of haemostatic overstitches apposed on the stapled suture, the area of the resected mucosa (in square centimetres) and any postoperative bleeding within 30 days were recorded. RESULTS: The mean area of the resected mucosa was significantly wider in EEA than PPH patients (35.75 ± 17.51 vs 28.05 ± 10.23 cm(2), P = 0.002). The median number of haemostatic stitches apposed in the EEA group was significantly lower than in the PPH groups (median value 1, vs 3, interquartile range 0-2, vs 2-5, P < 0.0001). Intraoperative haemostasis was better in the EEA group compared with the PPH01 and PPH03 groups. Postoperative bleeding occurred only in two PPH patients. CONCLUSION: Data suggest that the EEA stapler has better haemostatic properties than the PPH stapler and allows resection of a larger area of mucosal prolapse with potential benefits over the recurrence rate of haemorrhoid prolapse.

Randomized placebo-controlled trial on local applications of opioids after hemorrhoidectomy.

BACKGROUND: Hemorrhoidectomy is associated with considerable postoperative pain. This study assessed whether a small dose of morphine or oxycodone administered in the embedded sponge set in the anus at the end of a hemorrhoidectomy intervention reduced postoperative pain. METHODS: The presence of opioid receptors was assessed in the anal mucosa excised from ten patients with perianal condyloma acuminata and 19 patients with symptomatic third-fourth degree hemorrhoids. A double-blind prospective randomized placebo-controlled trial was then conducted in 135 patients with hemorrhoids. Hemorrhoidectomy patients were randomized to morphine (MG), oxycodone (OG), or control (CG) groups, each patient having an absorbable sponge dressing left in the anus embedded with 1 mg of morphine, 1 mg oxycodone, or vehicle, respectively. The mean time for the first dose of analgesic drugs, the use of analgesics, and the mean time to void bladder was evaluated. RESULTS: The presence of kappa- and delta-opioid receptor immunoreactivity was detected in the anal mucosa excised from patients with perianal condyloma acuminata and hemorrhoids. Furthermore, there was a significant (P < 0.001) upregulation of kappa receptor immunoreactive-like material in hemorrhoidectomy patients. The mean time for the first analgesic administration was significantly increased (P < 0.001) in MG versus CG. A further significant increase (P < 0.001) was observed in the OG patient group. The mean time for voiding was significantly higher in CG when compared to the MG and OG patient groups. CONCLUSION: The local administration of very low doses of kappa-opioid agonist decreased hemorrhoidectomy postoperative pain through the interaction with specific opioid receptors located on anal mucosa.

[Stapled hemorrhoidectomy: critical observation on state of art]. / Emorroidopessi con stapler: note critiche sullo stato dell'arte.

The authors review pros and cons of stapled hemorrhoidectomy (SH). Postoperative primary lower than after hemorrhoidectomy, but no data are available on the long term recurrences in large prospective series. Severe postoperative complications have been reported and SH seems less effective in patients with 4th degree files. SH is a useful technique, provided that proper indication are strictly followed and the procedure is carried out by specialists.

Hemofilia y AIDS / Hemophilia and AIDS

La población hemofilica tratada con concentraciones de factor VIII o IX liofilizado están expuestos a contraer el SIDA. El propósito de este trabajo es el dejar en claro si la infección por HIV por sí misma, independientemente de la dosis de anticoagulantes utilizados, sería capaz de producir alteraciones inmunológicas o clínicas. La conclusión fue que las fracciones de coagulantes liofilizados de factor VIII o IX existentes en el mercado, sí son capaces de producir alteraciones crónicas del I.C.M. y del I.V