Topical Lidocaine or Lidocaine/Diltiazem Ointment Following Rubber Band Ligation of Hemorrhoids: A Prospective 3-Armed Randomized Controlled Trial.

BACKGROUND: Rubber band ligation of hemorrhoids causes less pain than excisional hemorrhoidectomy, but many patients still experience significant postprocedure discomfort. OBJECTIVE: This study aimed to determine whether topical lidocaine, with or without diltiazem, is more effective than placebo for analgesia after hemorrhoid banding. DESIGN: This is a prospective, randomized, double-blinded, placebo-controlled trial. Patients were randomly assigned to 2% lidocaine, 2% lidocaine with 2% diltiazem, or a placebo ointment. SETTINGS: This study was performed at 2 university public teaching hospitals and 2 private hospitals in Australia. PATIENTS: Consecutive patients aged ≥18 years undergoing hemorrhoid banding were selected. INTERVENTIONS: Topical ointments were applied postprocedure 3× daily for 5 days. MAIN OUTCOME MEASURES: Visual analog pain score, opiate analgesia usage, and patient satisfaction were the main outcome measures. RESULTS: Of 159 eligible patients, 99 were randomly assigned (33 in each group). Pain scores were reduced at 1 hour for the lidocaine (OR 4.15 [1.12-15.41]; p = 0.03) and lidocaine/diltiazem groups (OR 3.85 [1.05-14.11]; p = 0.04) compared with placebo. Patients in the lidocaine/diltiazem group had improved satisfaction (OR 3.82 [1.28-11.44]; p = 0.02) and were more likely to recommend the procedure to others (OR 9.33 [1.07-81.72]; p = 0.04). Patients in the lidocaine/diltiazem group required approximately 45% less total and in-hospital analgesia compared with the placebo. There was no difference in complications between any of the groups. LIMITATIONS: A cost/benefit analysis was not performed. Analgesic efficacy appeared to be short term and the procedures were performed only in the hospital/nonambulatory setting. CONCLUSIONS: Topical lidocaine reduced short-term analgesia use, whereas combination lidocaine/diltiazem was associated with both improved analgesia and patient satisfaction after hemorrhoid banding. LIDOCANA TPICA O UNGENTO DE LIDOCANA/DILTIAZEM DESPUS DE LA LIGADURA HEMORROIDAL CON BANDA ELSTICA UN ENSAYO PROSPECTIVO CONTROLADO Y ALEATORIZADO DE TRES BRAZOS: ANTECEDENTES:La ligadura de hemorroides con banda elástica causa menos dolor que la hemorroidectomía escisional, pero muchos pacientes siguen experimentando molestias significativas tras el procedimiento.OBJETIVO:Este estudio tiene como objetivo determinar si la lidocaína tópica, con o sin diltiazem, es más eficaz que el placebo para la analgesia tras la ligadura hemorroidal.DISEÑO:Este es un ensayo prospectivo, aleatorizado, doble ciego, controlado con placebo. Los pacientes fueron aleatorizados para recibir lidocaína al 2 %, lidocaína al 2 % con diltiazem al 2 % o ungüento de placebo.AJUSTES:Este estudio se realizó en dos hospitales públicos con docencia universitaria y dos hospitales privados en Australia.PACIENTES:Se seleccionaron pacientes consecutivos de ≥18 años sometidos a ligadura para hemorroides.INTERVENCIONES:Se aplicaron ungüentos tópicos tras el procedimiento tres veces al día durante 5 días.PRINCIPALES MEDIDAS DE RESULTADO:La puntuación analógica visual del dolor, el uso de analgésicos opiáceos y la satisfacción del paciente fueron las principales medidas de resultado.RESULTADOS:De 159 pacientes elegibles, 99 fueron aleatorizados (33 en cada grupo). Las puntuaciones de dolor se redujeron a la hora para los grupos de lidocaína (OR 4,15 (1,12-15,41); p = 0,03) y lidocaína/diltiazem (OR 3,85 (1,05-14,11), p = 0,04) en comparación con el placebo.Los pacientes del grupo de lidocaína/diltiazem mejoraron su satisfacción (OR 3,82 (1,28-11,44), p = 0,02) y eran más propensos de recomendar el procedimiento a otros (OR 9,33 (1,07-81,72), p = 0,04). Los pacientes del grupo de lidocaína/diltiazem requirieron aproximadamente un 45 % menos de analgesia total e intrahospitalaria en comparación con el grupo de placebo. No hubo diferencia en las complicaciones entre ninguno de los grupos.LIMITACIONES:No se realizó un análisis de costo/beneficio. La eficacia analgésica pareció ser a corto plazo y los procedimientos solo se realizaron en el hospital/entorno no ambulatorio.CONCLUSIÓN:La lidocaína tópica mejora la analgesia a corto plazo, mientras que la combinación de lidocaína/diltiazem se asocia tanto con una mejor analgesia como con la satisfacción del paciente tras la colocación de bandas para hemorroides. (Traducción-Dr Osvaldo Gauto ).

Oncological and clinical outcomes after conventional right hemicolectomy.

PURPOSE: Complete mesocolic excision (CME) has been proposed for better local control of colon cancer and to improve cancer-specific survival (CSS). However, CME may be associated with increased morbidity from bleeding during central vascular ligation. This study aimed to investigate the outcome of conventional right hemicolectomy, a traditional anatomical dissection along anatomical planes with radical excision of the central lymph nodes at the level of the origin of colic artery but without exposure of superior mesenteric vein and artery (SMV/SMA). METHOD: This was a retrospective review of a cohort of all elective right hemicolectomies performed at a specialist tertiary unit during a five-year period (2011-2015). RESULTS: Five-hundred-nineteen patients (271 female, a median age of 73.0 years (interquartile range (IQR) 65.0-80.0)) were included (Stage I disease: 2.7%, stage II: 53.2%, stage III: 33.3%, stage IV: 10.8%). At the latest follow-up (a median 47 months (IQR 29-67)), local recurrence occurred in 34 patients (6.6%). Three-year overall survival was 74.4% and 3-year CSS was 85.9%. Subgroup analysis for stage I-III showed local recurrence in 6.0%, sole distant recurrence in 7.6% while 19 patients (4.1%) suffered concomitant local and distant recurrence. The anastomotic leak rate was 1.0% and perioperative bleeding occurred in 1.2%. CONCLUSIONS: Oncological outcomes comparable to those of CME can be achieved by conventional surgery but with low rates of bleeding complications and anastomotic leakage. The proposed advantages of CME should be carefully considered and balanced against patients' co-morbidities and potential complications.

Dystrophin and utrophin expression require sarcospan: loss of α7 integrin exacerbates a newly discovered muscle phenotype in sarcospan-null mice.

Sarcospan (SSPN) is a core component of the major adhesion complexes in skeletal muscle, the dystrophin- and utrophin (Utr)-glycoprotein complexes (DGC and UGC). We performed a rigorous analysis of SSPN-null mice and discovered that loss of SSPN decreased DGC and UGC abundance, leading to impaired laminin-binding activity and susceptibility to eccentric contraction-induced injury in skeletal muscle. We show that loss of SSPN increased levels of α7ß1 integrin. To genetically test whether integrin compensates for the loss of DGC and UGC function in SSPN-nulls, we generated mice lacking both SSPN and α7 integrin (DKO, double knockout). Muscle regeneration, sarcolemma integrity and fibrosis were exacerbated in DKO mice and were remarkably similar to muscle from Duchenne muscular dystrophy (DMD) patients, suggesting that secondary loss of integrin contributes significantly to pathogenesis. Expression of the DGC and UGC, laminin binding and Akt signaling were negatively impacted in DKO muscle, resulting in severely diminished specific force properties. We demonstrate that SSPN is a necessary component of dystrophin and Utr function and that SSPN modulation of integrin signaling is required for extracellular matrix attachment and muscle force development.

Actinomyces as a rare cause of appendicitis: a case report.

Actinomycosis remains a rare and often underdiagnosed cause of appendicitis with only 10% of cases diagnosed prior to surgery. It is an important cause to consider particularly in the setting of an indolent infection with nonspecific symptoms. We present a 22 years old male who presented with 3 weeks history of lower abdominal pain who underwent laboratory investigations and imaging studies suggestive of acute appendicitis. He underwent an emergency laparoscopic caecectomy with histopathology of the specimen suggestive of actinomycosis. He recovered well postoperatively and was discharged home with a prolonged course of oral penicillins. Preoperative diagnosis of actinomycosis is uncommon and accounts for ~10% of cases. Definitive diagnosis is usually through histopathology or tissue/fluid culture. Treatment usually involves a combination of surgical resection and antibiotic therapy with a success rate of >90%.

Patient-controlled analgesia compared with interval analgesic dosing for reducing complications in blunt thoracic trauma: a retrospective cohort study.

OBJECTIVES: To determine if complications from blunt thoracic trauma are reduced with patient-controlled analgesia (PCA) compared with interval analgesic dosing given as needed. Secondary aims were to investigate the influence of PCA on hospital length of stay (LOS) and cost. METHODS: In this retrospective cohort study, patients were identified using the hospital trauma registry and clinical information department. Data on analgesic method, outcomes and confounders were obtained from the medical record. Costing data were obtained from the case-mix department. The analysis used logistic regression for the primary outcome and a generalised linear model for the secondary outcomes to adjust for potential confounders. RESULTS: 227 patients were included. In the PCA group, 17/52 (33%) patients had a complication compared with 26/175 (15%) in the interval dosing group. The adjusted odds for a complication in patients receiving PCA was not significantly different from the adjusted odds in those receiving interval dosing (OR=1.2, 95% CI 0.3 to 4.6, p=0.83). The median LOS was 8.9 days in the PCA group and 4.6 days in the interval dosing group. The adjusted LOS for patients receiving PCA was 10% shorter than those receiving interval dosing (relative difference 0.9, 95% CI 0.6 to 1.3, p=0.52). The median hospital cost was $A11 107 in the PCA group (IQR $A7520-$A15 744) and $A4511 (IQR $A2687-$A8248) in the interval dosing group. The adjusted total hospital costs for patients receiving PCA was 10% higher than for those receiving interval dosing (relative difference 1.1, 95% CI 0.8 to 1.5, p=0.44). CONCLUSIONS: PCA did not reduce complications, hospital LOS or costs compared with interval analgesic dosing.

Trichobezoar as a cause of pediatric acute small bowel obstruction.

This case serves to raise awareness of trichobezoar as a diagnosis in young children who present with abdominal pain, a palpable mass, and signs of acute small bowel obstruction.

Systematic review and meta-analysis of the association between diverticulosis of the appendix and neoplasia.

BACKGROUND: Diverticula of the appendix (DA) are infrequent and their clinical implications are often overlooked. Several studies have found a significantly increased prevalence of neoplasms in appendiceal specimens with diverticula. Despite the potential clinical implications, there is a paucity of literature. A systematic review and meta-analysis was performed to evaluate the prevalence of DA and its association with neoplasia. METHODS: A systematic search of literature (Cochrane, EMBASE, PubMed and Medline) reporting the prevalence of DA and association with neoplasia was performed in November 2019. Relevant articles were assessed in accordance with the PRISMA guidelines. Risk of bias assessment was carried out using modified Newcastle-Ottawa scale. Meta-analysis with risk ratio and random-effects model was performed using RevMan. RESULTS: The initial search identified 1122 potential articles of which 11 were appropriate for quantitative analysis. The prevalence rate of DA was 1.74%. The mean age of patients with DA and those without DA was 41.2 and 33.9 years, respectively. The ratio of male to female was 1.8:1. The prevalence of neoplasia in specimens without DA versus those with DA was 1.28% and 26.94%, respectively. Only four studies addressed the prevalence of locoregional neoplasia in the setting of DA compared to control. Meta-analysis with random-effects model demonstrated that pooled risk ratio was 25.46 (95% confidence interval 12.77-50.75, P < 0.00001). CONCLUSION: The strong association with neoplasia in this meta-analysis reinforces the clinical significance of DA. Surgeons, pathologists and radiologists should be mindful of this uncommon pathology and consider individualized patient management, until further evidence can direct clinical guidelines for the management of patients with DA.

Atraumatic splenic rupture after cocaine use and acute Epstein-Barr virus infection: A case report and review of literature.

BACKGROUND: Atraumatic splenic rupture (ASR) accounts for just over 3% of all cases of splenic rupture and is associated with a high mortality rate. The most common culprit is acute infection with Epstein-Barr virus (EBV) but other documented aetiologies include neoplasia, other viral/bacterial infections, acute and chronic pancreatitis, amyloidosis and anticoagulant medications. There are four previous reports of cocaine-associated ASR but never before has it been documented in combination with concurrent acute EBV infection. CASE SUMMARY: A 21-year-old man presented to hospital with acute left shoulder pain which radiated to the right shoulder and upper abdomen. He denied any history of recent trauma and had no relevant past medical history. He took no regular prescription medications but had used cocaine within the previous 24 h. Investigations revealed splenomegaly, a Grade 3 subcapsular splenic haematoma, moderate haemoperitoneum and an incidental 9 mm splenic artery pseudoaneurysm. There was also serological evidence of acute EBV infection. Prophylactic endovascular embolisation of the pseudoaneurysm was performed and the splenic rupture was managed non-operatively. The patient remained admitted in hospital for seven days and did not require any transfusion of blood products. Serial imaging showed complete resolution of the haemoperitoneum after 5 wk. The importance of abstinence from illicit drug use was emphasised to the patient but it is unknown whether or not he remains compliant. CONCLUSION: This case demonstrates that ASR is a rare condition that can result from acute EBV infection and cocaine ingestion and requires a high index of suspicion to diagnose clinically.

Leflunomide-induced colitis in association with enterocutaneous fistula in an immunosuppressed patient with renal transplant and rheumatoid arthritis.

We describe the case of a 68-year-old man who has a complex medical background that included renal transplantation, rheumatoid arthritis and atrial fibrillation. Because of this, he was taking a number of immunosuppressant medications including leflunomide, prednisone and tacrolimus. He had experienced chronic diarrhoea over 18 months which had acutely worsened over the 6 weeks prior to hospital presentation. Recent colonoscopies had been performed to investigate this diarrhoea with biopsies revealing acute and chronic inflammatory changes in the terminal ileum and colon. No infectious cause could be found, with all bacterial and viral stool cultures returning negative. An enterocutaneous fistula had also spontaneously developed through his renal transplant scar in the days preceding hospital admission which complicated the clinical picture. Following dose reduction of leflunomide, there was a significant improvement in the frequency and severity of the patient's diarrhoea. He continues to be managed non-operatively for his fistula as he is at high risk of peri-operative morbidity and mortality.

Acquired segmental colonic hypoganglionosis in an adult Caucasian male: A case report.

BACKGROUND: Hypoganglionosis is a rare condition that most often presents with abnormal gastrointestinal transit and usually arises in early childhood or adolescence. Two types have been described (Type I and Type II). The adult-onset form (acquired hypoganglionosis) is extremely uncommon and is thought to arise due to cellular remodelling as a result of chronic inflammation. It differs from Hirschprung's disease in that there is a reduction in ganglion cells in the colonic neural plexuses as opposed to being completely absent. CASE SUMMARY: A 31 year-old male presented to hospital with recurrent abdominal pain and vomiting over thirteen months. Abdominal computed tomography scans demonstrated thickening and stranding affecting the transverse, descending and sigmoid colon. Endoscopic appearances were non-specific but confirmed a mixed picture of mucosal inflammation and necrosis in various stages of healing. Numerous investigations were performed to elucidate an underlying aetiology but neither an infective nor ischaemic cause could be proven. Biopsy features were not typical of inflammatory bowel disease. Due to persistence of his symptoms and failure of medical management, a segmental colectomy was performed. Histological examination of the specimen revealed an unexpected finding of segmental hypoganglionosis. Complete surgical excision of the diseased segment of colon was curative and since his operation the patient has had no recurrence of symptoms requiring hospitalisation. CONCLUSION: Our case serves to raise awareness of acquired hypoganglionosis as a rare condition that can result from chronic colitis.

A case of tension faecopneumothorax after delayed diagnosis of traumatic diaphragmatic hernia.

BACKGROUND: Traumatic diaphragmatic injuries from blunt or penetrating trauma are difficult to detect in the acute setting and, if missed, can result in significant morbidity and mortality in the future. We present a case demonstrating the natural progression of this resulting in faecopneumothorax, which is a rare but serious presentation. CASE PRESENTATION: A 22-year-old young man presented with left upper quadrant and chest pain, nausea, vomiting, and intermittent obstipation with a background of previous lower chest wall stabbings. Computed tomography demonstrated a diaphragmatic hernia containing the splenic flexure of the colon, but he declined treatment and self-discharged. He presented three more times with similar symptoms and self-discharged within a 2-week period and finally presented dyspnoeic and septic. Computed tomography demonstrated tension faecopneumothorax from the perforated colon. He was taken to theatres and found to have a 3-mm perforation at his splenic flexure and underwent a segmental resection of the affected colon, intrathoracic washout, and biological mesh repair of his diaphragmatic hernia. He remained alive and postoperative recovery was uneventful. CONCLUSIONS: A review of the literature demonstrates the rarity of traumatic diaphragmatic injuries resulting in faecopneumothorax with only a few case reports in the last 50 years. We present a case demonstrating a natural progression of the condition and highlight the importance of having a high index of suspicion of diaphragmatic injuries in the trauma setting.

Acute cholecystitis and gallbladder perforation leading to massive haemoperitoneum in a patient taking rivaroxaban.

We present the case of an 80-year old man taking rivaroxaban for atrial fibrillation who sustained massive intra-abdominal bleeding in the setting of acute cholecystitis. CT scan on admission revealed evidence of active bleeding into the gallbladder lumen and gallbladder perforation. Immediate resuscitation was commenced with intravenous fluids, antibiotics and blood products. Despite attempts to correct coagulopathy, the patient's haemodynamic status deteriorated and an emergency laparotomy was performed, with open cholecystectomy, washout and haemostasis. The patient had a largely uneventful recovery and was discharged on day 11 of admission. Patients with coagulopathies, whether pharmacological or due to underlying disease processes, are at very high risk of severe haemorrhagic complications and subsequent morbidity. As such, prompt recognition and operative management of haemorrhagic perforated cholecystitis is of crucial importance.