Stapled hemorrhoidopexy: “mucosectomy or not only mucosectomy, this is the problem”

Introduction: Stapled hemorrhoidopexy was originally defined as a rectal mucosectomy. The aims of our retrospective, single-center study were to demonstrate if the excised specimen comprises only the mucosa or more wall rectal layers and if the latter excision should be considered a technical mistake with an increase in complications. Materials and Methods: We histopathologically analyzed surgical samples from patients who underwent stapled hemorrhoidopexy performed between 2014 and 2019. Patients were divided into three groups, according to the stapler used: Group A (single PPH®), Group B (double PPH®), and Group C (CPH34 HVTM). We evaluated the actual wall layers included in the stapled rectal ring. For every specimen, we reconstructed the history of the corresponding patient and the incidence of complications. Results: Of the 137 histological slides available, 13 were only mucosectomies (9.5%), and 124 presented also the submucosa and muscularis propria (90.5%)−50/58 patients in Group A, 28/28 in Group B, and 46/51 in Group C. No statistically significant difference in the rate of complications was found when stratifying patients according to the thickness of the resection [mucosectomy (M) or “full thickness” (FT)]. Discussion: Stapled hemorrhoidopexy is not a simple mucosectomy but a resection of the rectal wall with almost all its layers. This concept defines the entity of the surgical procedure and excludes a direct correlation with an increased rate of complications

Impact of uni- or multifocal perineural invasion in prostate cancer at radical prostatectomy

Background: Aim of this study was to correlate perineural invasion (PNI) with other clinical-pathological parameters in terms of prognostic indicators in prostate cancer (PC) cases at the time of radical prostatectomy (RP). Methods: Prospective study of 288 consecutive PC cases undergoing RP. PNI determination was performed either in biopsy or in RP specimens classifying as uni- and multifocal PNI. The median follow-up time was 22 (range, 6-36) months. Results: At biopsy PNI was found in 34 (11.8%) cases and in 202 (70.1%) cases at the time of surgery. Among those identified at RP 133 (46.1%) and 69 (23.9%) cases had uni- and multi-PNI, respectively. Presence of PNI was significantly (P<0.05) correlated with unfavorable pathological parameters such higher stage and grade. The percentage of extracapsular extension in PNI negative RP specimens was 18.6% vs. 60.4% of PNI positive specimens. However, the distribution of pathological staging and International Society of Urological Pathology (ISUP) grading did not vary according to whether PNI was uni- or multifocal. The risk of biochemical progression increased 2.3 times in PNI positive cases was significantly associated with the risk of biochemical progression (r=0.136; P=0.04). However, at multivariate analysis PNI was not significantly associated with biochemical progression [hazard ratio (HR): 1.87, 95% confidence interval (CI): 0.68-3.12; P=0.089]. Within patients with intermediate risk disease, multifocal PNI was able to predict cases with lower mean time to biochemical and progression free survival (chi-square 5.95; P=0.04). Conclusions: PNI at biopsy is not a good predictor of the PNI incidence at the time of RP. PNI detection in surgical specimens may help stratify intermediate risk cases for the risk of biochemical progression

Usefulness of Endoscopic Small Intestinal Biopsies In Children With Coeliac Disease.

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[Ascaridiasis: a rare cause of recurrent abdominal pain. Report of a clinical case documented by ultrastructural study of the intestinal mucosa].

The case of a six-year-old girl suffering from recurrent abdominal pain is reported. On the basis of the laboratory tests and a number of other clinical investigations, the diagnosis of ascaridiasis was made. At scanning electron microscopy the ultrastructural study of the bioptic fragments obtained during endoscopy showed peculiar lesions of the gastric and duodenal mucosa. We speculate that this unusual picture may be due to the ascaris. These lesions, described for the first time in the literature to our knowledge, were represented by the loss of the apical portion of some cells. Differential diagnosis of recurrent abdominal pain is discussed

ARTERIAL REPAIR AFTER MICROVASCULAR ANASTOMOSIS - SCANNING AND TRANSMISSION ELECTRON-MICROSCOPY STUDY

In order to study the morphological aspects of endothelial regeneration and vascular wall reaction after microvascular anastomosis, rat femoral arteries were sectioned and successively sutured (end-to-end anastomosis) with microsurgical techniques. Control arteries and anastomosed vessels (recovered after 1, 4, 7, 14, 21, 30, 60, 120, 180 and 360 days) were studied by means of scanning (SEM) and transmission electron microscopy (TEM). The reendothelialization phenomena started after 7 days and were mainly evident at 21 days. Areas of subendothelial connective tissue with fibrin deposition remained exposed to the blood stream up to 21-30 days. Thrombus formations or postanastomotic stenosis have been occasionally observed. Regenerating endothelium showed evident morphological differences from the control. These changes mainly consisted of shortened cell length, absence of pinocytotic vesicles, presence of cytoplasmic prolongations, and microvillous proliferations. The arterial wall showed subintimal thickening. The anastomotic site appeared completely covered by new endothelium after 30-60 days. Subintimal vascular wall changes (thickening of the media) as well as slight alterations of endothelial cells (shortened length, reduced number of pinocytotic vesicles) were evident in 60-day vessels. Lumen reduction, due to the protruding of endothelial-covered sutures, was occasionally observed in 60- to 120-day arteries. Endothelial cell morphology normalized after 60-120 days. However, thickening of the media and occasional lumen reduction were observed also after 180-360 days. Although the endothelial regeneration phenomena were clearly evident after 2 weeks, nevertheless the reestablishment of arterial wall took longer time. In fact, paralleled SEM and TEM observations made it possible to recognize three different kinds of arterial changes: (1) Temporary changes consisting of a highly thrombogenic exposed subintimal connective tissue (1-30 days) and of regenerating endothelium morphologically different from control endothelium (14-60 days); (2) permanent changes characterized by thickening of the media, and (3) occasional changes corresponding to reduction of the vessel caliber. Temporary changes may be shortened by adquate therapy. Endothelial changes may represent the sign of an impaired endothelial function. Permanent changes are due to a hyperplastic-inflammatory reaction, and are probably related to the natural history of arterial wall injury. Occasional changes may be related to poor microsurgical technique. Therefore, these alterations should be taken into consideration when setting therapeutic protocols and evaluating the reasons for arterial anastomosis failure