Stapled versus conventional surgery for hemorrhoids.

BACKGROUND: Hemorrhoids are one of the most common anorectal disorders. The Milligan­Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized­controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day­case procedures potentially making it more economical. A previous Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow­up. Since this initial review, several more randomized controlled trials have been published that may shed more light on the differences between the novel stapled approach and conventional excisional techniques. OBJECTIVES: This review compares the use of circular stapling devices and conventional excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether there is any difference in the outcomes of the two techniques in patients with symptomatic hemorrhoids. SEARCH STRATEGY: We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009. SELECTION CRITERIA: All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries with a minimum follow­up period of 6 months were included. DATA COLLECTION AND ANALYSIS: Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model. MAIN RESULTS: Patients with SH were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI 1.59­6.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.24­10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (13 studies, 1191 patients, OR 2.65, CI 1.45­4.85, p=0.002). In studies with follow up of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR 3.14, CI 1.20­8.22, p=0.02). Patients undergoing SH were more likely to require an additional operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI 1.31­5.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.40­0.88). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH.

Can the procedure for prolapsing hemorrhoids (PPH) be done twice? Results of a porcine model.

BACKGROUND: The procedure for prolapsing hemorrhoids (PPH) is a new surgical method for the treatment of symptomatic hemorrhoids. In cases of recurrent prolapse, the performance of a second PPH may result in a ring of mucosa and submucosa between the two circular staple lines. In this study, we used a porcine model to assess whether PPH can be safely performed twice. METHODS: Five adult pigs underwent two PPH procedures in one session, leaving a ring of approximately 1 cm of mucosa between the two staple lines. One month later, the pigs were examined under anesthesia. The anal canal was assessed using the following four methods: (a) clinical examination, (b) evaluation of mucosal blood perfusion at different levels of the anal canal via a laser Doppler flow detector, (c) measurement of concentrations of hydroxyproline and collagen to check for fibrosis, and (d) histopathological examination. RESULTS: At the completion of the study period, all five pigs showed no clinical evidence of anorectal dysfunction. On examination under anesthesia 1 month after surgery, there was no evidence of anal stenosis in any of the pigs. The mean mucosal blood flow between the two staple lines did not differ significantly from the flow measured proximally and distally (394 vs 363 and 339 flow units, respectively; p = NS). The collagen levels, based on hydroxyproline concentration, were 81 mcg/mg between the staple lines, compared to 82 and 79 proximally and distally, respectively ( p = NS). There was no significant difference in degree of fibrosis, as assessed histopathologically, between specimens taken from the ring between the staple lines and specimens taken from the area external to the staple lines. CONCLUSIONS: The results of this porcine model suggest that a second synchronous PPH is feasible. A controlled experience involving human subjects is required to determine the safety and usefulness of this technique in cases of metachronous application for recurrent or residual hemorrhoids.

The New South Wales mastitis control program. 2. Effect upon bacterial infections.

Bacteriological examinations were made on quarter samples from cows in 35 herds over a 3 year period to monitor the response in a mastitis control program. Initially, Staphylococcus aureus predominated in 32 of the herds and the mean herd prevalence was 26%. The control measures halved this rate but there was considerable variation in response between herds. The decline occurred rapidly and there was a significant reduction (P less than 0.01) by 3 months. Streptococcus agalactiae predominated in 3 herds and the overall infection rate was 4.9%. Control measures eliminated the infection completely from most herds but reinfection occurred in 2 herds. The greatest decline occurred in the first 6 months and was significant (P less than 0.05). The measures had little effect upon Str. uberis and Str. dysgalactiae which remained fairly consistently at low levels. Initially, strains of Staph. aureus resistant to penicillin were dominant in most herds. In a minority of herds strains resistant to streptomycin predominated and in these herds there was a concurrent resistance to penicillin. These patterns did not change greatly over the control period. Resistance by Str. agalactiae to streptomycin occurred in most herds at the start of the program.

Epithelial and mesothelial basement membranes in diabetic patients and dogs.

The influence of diabetes on the thickness of basement membrane of the ciliary epithelium, lens epithelium, and corneal mesothelium (endothelium) was investigated post mortem in eyes from 27 human subjects and 30 dogs. Ten of the human subjects were diabetic, 10 were non-diabetic matched for age and sex, and seven were non-diabetic subjects who had been diagnosed as hypertensive 2-8 years before death. The dogs comprised three prospectively identified groups: 10 were alloxan diabetic for 5 years and kept in poor glucose control, 10 were alloxan diabetic for 5 years and kept in good glucose control, and 10 were non-diabetic animals. Basement membranes at the three sites measured appeared to be normal in the seven non-diabetic hypertensive subjects. Basement membrane of the ciliary epithelium was found to be significantly thicker than normal both in diabetic human subjects and in poorly controlled diabetic dogs. The thickness of the anterior lens capsule was significantly greater in poorly controlled diabetic dogs than in non-diabetic dogs, and showed a significant positive correlation with duration of diabetes in human subjects. Better glucose control in diabetic dogs resulted in significant inhibition of the epithelial basement membrane thickening. The basement membrane of the corneal mesothelium failed to thicken with diabetes both in human subjects and in animals.

Indirect photocoagulation of subfoveal choroidal neovascularization in age-related macular degeneration.

Forty consecutive patients with age-related macular degeneration and a choroidal neovascular membrane in the center of the macula were treated by dye laser photocoagulation. After a mean 24 month follow-up period, 21 patients (52.5%) remained stable or improved in vision. Of 21 patients with initial visual acuity of 20/100 or better, 11 patients (52%) remained 20/100 or better. In the control group only four patients (25%) remained stable or improved, and only two (15%) remained 20/100 or better. The theoretical and clinical advantages of the indirect laser treatment of subfoveal choroidal neovascular membranes in age-related macular degeneration are discussed.

Work at sea: a study of sleep, and of circadian rhythms in physiological and psychological functions, in watchkeepers on merchant vessels. IV. Rhythms in performance and alertness.

Performance scores on both a simple detection task and a complex visual judgment task, together with subjective alertness ratings, were collected 4-hourly from 19 watchkeepers working a "4-on/8-off" routine, and from 20 dayworkers, over consecutive days of voyages on merchant ships. Adaptation of the circadian rhythms in the measures to the shifted hours of work of the three sections of the watchkeeping crews was at best only partial. These rhythms resulted in a depression of the levels of most measures during the night hours, which was exacerbated by the effects of recent awakening from sleep. It is suggested that these unwanted variations in operational effectiveness could be largely removed by replacing the 4-on/8-off watchkeeping system, with its associated "split" sleep pattern, by one which allows a single full length sleep each day. Such a system would encourage better adaptation of the rhythms; effects of recent awakening could be avoided by the provision of an adequate "waking up" period before duty begins.

Adjustment of the oral temperature rhythm to a fixed watchkeeping system on board ship.

Oral temperature data were collected from 12 members of the crew of an oil tanker at sea. Most of the personnel examined were engaged on watchkeeping duties on a '4 on, 8 off' fixed-hours system; the remainder included 3 "day-workers". The study commenced after the subjects had been following their particular work schedules continuously for several weeks, thus providing good opportunity for adaptation to them. Observations were made at 4-hourly intervals during waking hours, over a period ranging from 8 to 13 days in individual cases. The form of the mean curves produced by averaging the readings over all days indicated that a reasonable degree of adjustment of the temperature rhythm to the different sleep/wake routines imposed by the work system had occurred. Estimates of rhythm phase and amplitude obtained by "single cosinor" time series analyses of the sequential data supported this impression. However, further investigations are needed to substantiate these findings, and also to determine how long it takes for the rhythm adjustment process to reach completion in inexperienced workers.

In vitro phosphorylation of bovine cardiac muscle high molecular weight calmodulin binding protein by cyclic AMP-dependent protein kinase and dephosphorylation by calmodulin-dependent phosphatase.

High molecular weight calmodulin binding protein (HMWCaMBP) is one of the major proteins expressed in bovine cardiac muscle. In this study, we report the phosphorylation and dephosphorylation of HMWCaMBP in vitro with a view to understand the function of this protein. The HMWCaMBP was phosphorylated by cAMP-dependent protein kinase with the incorporation of 2.30 mol of phosphate/mol of protein in the presence of EGTA. When phosphorylation was carried out in the presence of Ca2+/calmodulin (CaM), the incorporation of phosphate was reduced to 1.40 mol of phosphate/mol of protein. The decrease in the stoichometry of phosphorylation by Ca2+/CaM appears to be substrate directed i.e. due to the interaction of Ca2+/CaM with HMWCaMBP. The phosphorylated HMWCaMBP was unable to compete for free CaM in a CaM-dependent cyclic nucleotide phosphodiesterase (CaMPDE) assay. These results suggest that the phosphorylation sites may reside in or in proximity to the CaM-binding domain on HMWCaMBP since phosphorylated HMWCaMBP did not inhibit CaMPDE activity. HMWCaMBP was dephosphorylated by CaM-dependent phosphatase, calcineurin.

High compliance rates observed for follow up colonoscopy post polypectomy are achievable outside of clinical trials: efficacy of polypectomy is not reduced by low compliance for follow up.

INTRODUCTION: The National Polyp Study demonstrated that removal of adenomas with at least a three-year follow up reduced the incidence of colorectal cancer. However, compliance with follow up colonoscopy may affect the estimates of reduction in colorectal cancer incidence demonstrated by the National Polyp Study. While an 80% compliance rate for follow up colonoscopy was achieved during the National Polyp Study, the compliance rate for follow up colonoscopy is unknown in the general population. The aim of this study was to determine the compliance rate for follow up colonoscopy and factors which affect follow up. METHODS: A retrospective medical record review to identify patients who had adenomatous polyps excised in 1997 was undertaken. Patients who had inflammatory bowel disease, a prior history of colorectal cancer, familial adenomatous polyposis syndrome, colonic surgery; incomplete polypectomy or incomplete colonoscopy, and those patients who died before planned follow up, were excluded from analysis. Follow up was performed by telephone survey. RESULTS: Three hundred and thirty-three patients were identified (196 males; 147 females) with a mean age of 70 years. Three hundred and thirty-one (99%) of 333 had a documented recommendation for follow up of three years or less. Thirty-four percent (113 of 333) had previously undergone colonoscopy; 29% (98 of 333) had previously undergone polypectomy and 54% (180 of 333) were symptomatic at the time of the colonoscopy. Twenty-eight percent (40 of 141) had a family history of colorectal cancer. Pathology at polypectomy included a single polyp and polyps less than 10 mm in 68% and 88% of cases, respectively. Follow up was available in 211 of these cases, 179 (85%) of which had been compliant with follow up colonoscopy. In a univariate analysis, previous colonoscopy (P = 0.035), previous polyps (P = 0.043), asymptomatic status at time of colonoscopy (P = 0.021), polyp size (P = 0.008) and number of polyps (P = 0.010) were significantly associated with patients who were compliant with follow up colonoscopy. A multivariate logistics regression analysis revealed number of polyps (P = 0.036) and polyp size (P = 0.045) to be statistically significantly associated with compliance. CONCLUSION: Compliance with follow up colonoscopy after polypectomy is greater than 80%, regardless of age, education, family history, prior colonoscopy, or prior polypectomy. Risk reduction published in the National Polyp Study may likely reflect what can be achieved through the general use of colonoscopy for surveillance.