Recurrent hemorrhoidal disease after stapled prolassectomy: hypothesis on predictive factors and surgical management

INTRODUCTION The surgical procedure of stapled haemorrhoidopexy is now considered safe and its safety is improving with experience and technical upgrading. Compared to conventional procedures, stapled haemorrhoidopexy has the advantage - in the short term results - of less postoperative pain but the main disadvantage - in the long term follow-up- of possible recurrent prolapse. This occurs between three months and one year after the operation and should be differentiated -for a more correct evaluation of the results- by the persistent prolapse, that is immediately evident after surgery or in the first two months. Both –persistent and recurrent prolapse- required treatment if symptomatic. The percentage of symptomatic prolapse -persistent and recurrent- after stapled procedures varies widely in the several clinical trials described in the literature, ranging from a minimum of 2% to the worst results of 53.3% (1-9). The unsatisfactory results mainly depend on incorrect indications (IV grade haemorrhoids with predominant external, fibrous component), technical mistakes during surgical procedure and insufficient prolapse correction. Avoiding or minimizing the possibility of a recurrent prolapse should be demanded to a well realized primary operation, calibrated on the effective amount of the prolapse (using single or double stapled technique, instruments with larger case, parachute technique, or with an immediate, intraoperative correction of the persistent prolapse or excision of a residual pile). The aim of this work is to analyze the different features of recurrences after stapled haemorrhoidal operations and the procedures realized to treat them in order to lay down solid and firm starting points to focalize some guidelines of treatment of recurrences after stapled prolapsectomy MATERIAL AND METHODS We performed a retrospective study on 69 patients, affected by recurrent or residual prolapse after a primary operation of stapled haemorrhoidopexy (58 patients treated with a single PPH -PPH- and 11 with a double stapling procedure -DSPPH-) and undergoing reoperative surgery for the treatment of recurrence (Table I). This cohort of patients was recruited between January 2005 and January 2011 in three Italian national reference centers for proctological surgery (Pisa, Rome and Pordenone) and was retrospectively analyzed. RESULTS The symptoms of primary onset had been: haemorrhoidal crisis in 17 patients, bleeding in 5 patients, prolapse in 45 patients and finally both prolapse and bleeding in 2 patients. (Table 2) 58 out of 69 patients had undergone a PPH at the primary operation and 11 out of 69 a DSPPH. In 23 patients (34%) primary surgery had been performed in other Hospitals. Prolapse degree according to Goligher’s classification was: II degree in 15 cases, III degree in 36 cases, IV degree in 18 cases (Table 3). The mean time of recurrence was 18 months (range 2-42 months) in the 58 patients, who had undergone a PPH and 12 months (range 2-42 months) in those who had undergone a D-PPH (Table 4). All operations were performed at least six months after the onset of the recurrence’s symptoms. Only two patients underwent a reoperation after about two months for a haemorrhoidal thrombosis. The clinical onset of recurrence appeared in the form of: haemorrhoidal crisis in 12 patients, bleeding in 8 patients, recurrent prolapse in 29 patients and residual prolapse in 20 patients (Table 5). Intraoperative findings in the 58 patients, who had undergone a previous single PPH, were: 30 recurrent or residual prolapsed haemorrhoids with single or multiple piles- ≤3- (17 residual and 13 recurrent), 4 congested haemorrhoids, 18 mobile prolapse, 6 mobile prolapse associated with thrombosed haemorrhoids. In these cases the operations chosen were: 34 excisional surgery, 12 PPH, 6 DSPPH, 6 PPH plus excisional surgery. Intraoperative findings in the 11 patients, who had undergone a previous DSPPH, were: 6 recurrent or residual prolapsed haemorrhoids with single or multiple piles- ≤3- (3 residual and 3 recurrent), 2 congested haemorrhoids, 2 mobile prolapse, 1 mobile prolapse associated with thrombosed haemorrhoids. In these cases the operations chosen were: 8 excisional surgery, 1 PPH, 1 DSPPH, 1 PPH plus excisional surgery. Table 6 and 7 describe the intraoperative reports after a previous PPH and after a previous DSPPH and the operations applied. The preoperative and postoperative management (use of painkillers drugs, antibiotics and laxatives), the kind of anaesthesia -general or local- of the patients undergoing reoperative surgery for recurring haemorrhoids was similar to that applied in the first operation. The mean operative time was comparable to that of the primary surgery in patients treated with PPH or DSPPH or excisional surgery. The hospital stay and return to full activity were similar to the primary operations. Postoperative complications after a “stapled” operation (PPH, DSPPH) and after a “non stapled”operation are summarised in Table 8. They were comparable to those relative to primary surgery. In the “stapled” group bleeding occurred in 3 patients. In one case the bleeding was controlled by introducing a Foley catheter into the anorectum and by inflating its balloon at 30-40 cm3, one case was coped with a local application of a hemostatic device, one case required a surgical revision under anaesthesia. In the “non stapled” group, instead, bleeding occurred in 1 patient and required a surgical revision. 2 patients in the “stapled” group and 2 patients in the “non stapler” group complained of urgency but this symptoms solved spontaneously one month after operation. Postoperative pain was under control in both group thanks to the use of the routine FANS usually employed. However, there were 2 patients in the “stapled” group and 2 patients in the “non stapler” group, who reported persisting anal pain in the 2 weeks following operation and required further use of painkillers. After this time, the pain symptoms disappeared in these three patients and continued in the other one. The mean follow-up after reoperative surgery resulted in 40 months (range, 23-96) No cases of second recurrence occurred in the treated patients. The outcome assessed on the basis of the clinical examination, as well as at the opinion expressed by the patients was excellent in 34 patients, good in 23 patients, sufficient in 8 patients, poor in 4 patients because two considered their symptoms (bleeding and congested haemorrhoids) unchanged, one reported a worsening of constipation and another complained of persistent pain. DISCUSSION The presence of a residual or recurrent prolapse can be derived or from an incorrect indication to surgery or from an insufficient resective approach. Alternatively it may be due to an operation, which had been previously carried out incorrectly with an insufficient pull of the prolapsed tissue in the operative case. In case of recurrence, symptoms guide to the decision of a reoperation and the surgical technique is determined according to the intraoperative report, that in almost equal percentage is divided between the mobility of the prolapse and the presence of recurrent and/or residual haemorrhoidal prolapsed piles. In the case of a mobile prolapse the choice was a transrectal resection with stapler (PPH or DSPPH, depending on the amount of the prolapse that should be resected). On the contrary, in the case of a fixed prolapse or single or multiple piles -≤3_, the choice should be a traditional surgery (Milligan Morgan, whatever performed). In case of multiple piles ≥3 the choice is a transrectal resection with stapler (PPH or DSPPH, depending on the amount of the prolapse that should be resected). A PPH combined with Milligan Morgan Haemorrhoidectomy is applied in case of a mobile prolapse with some residual pile. CONCLUSIONS Avoiding or minimizing the possibility of a recurrent prolapse should be demanded to a well realized primary operation, calibrated on the effective amount of the prolapse. A complete clinical study with a correct evaluation of the symptoms and a careful intraoperative assessment of the recurrence’s features are of primary importance for the choice of the technique to be applied. Re-excisional surgery but also a re-stapled procedure can be safely and successfully realized with the same operating methods of a primary operation, with no more complications or difficulties

L’adenocarcinoma dell’appendice ileo-ciecale: presentazione di un caso clinico e revisione della letteratura

L’adenocarcinoma dell’appendice ileo-ciecale è una neoplasia di rara osservazione rappresentando meno dello 0,5% di tutti i tumori dell’apparato gastrointestinale. Nella maggior parte dei casi viene diagnosticato all’esame istologico definitivo di un’appendice asportata per flogosi, talora invece rappresenta un reperto del tutto inatteso, documentato da biopsie estemporanee, in corso di intervento chirurgico eseguito per sospetta appendicite acuta o altra patologia non appendicolare. La storia naturale di tale neoplasia è fortemente condizionata dalle peculiari caratteristiche anatomiche del viscere che ne favoriscono la precoce diffusione e una notevole tendenza alla perforazione. Si associa frequentemente ad altre neoplasie primitive, sincrone o metacrone, a localizzazione colo-rettale o extraintestinale. Il trattamento chirurgico oncologicamente corretto è l’emicolectomia destra che può essere eseguita come prima procedura, nei casi in cui la neoplasia venga diagnosticata pre- o intraoperatoriamente, o come seconda procedura, due-tre settimane dopo l’appendicectomia, qualora soltanto l’esame istologico dell’appendice asportata riveli la presenza dell’adenocarcinoma. L’emicolectomia destra è il trattamento chirurgico più idoneo in tutti gli istotipi (colico, mucinoso, adenocarcinoide), in presenza di perforazione ed anche nelle neoplasie allo stadio A di Dukes. Durante l’atto operatorio è necessario effettuare un’accurata esplorazione della cavità addominale per la ricerca di neoplasie sincrone, mentre dopo l’intervento i pazienti dovranno essere sottoposti ad un follow-up regolare e prolungato nel tempo onde diagnosticare precocemente eventuali neoplasie metacrone. Riportiamo il caso di una donna di 78 anni con adenocarcinoma dell’appendice scoperto casualmente in corso di intervento chirurgico eseguito per un quadro di occlusione intestinale da sospetta neoplasia del cieco

Carcinoma paratiroideo: caso clinico e revisione della letteratura

Introduzione. Il carcinoma paratiroideo è una neoplasia endocrina rara, di difficile inquadramento clinico ed istopatologico. È responsabile di meno del 1% dei casi di iperparatiroidismo primitivo. Caso clinico. Viene presentato il caso di un paziente di 20 anni, con situs viscerum inversus (destrocardia), che riferiva la recente comparsa di una sintomatologia, rapidamente ingravescente, caratterizzata da astenia, oliguria, nausea, vomito, mialgie, parestesie degli arti inferiori e confusione mentale; i valori di calcemia e PTH erano molto elevati. Gli esami di laboratorio eseguiti nel corso del ricovero (PTH 580 pg/ml; Ca 12.40 mg/dl; P 1.9 mg/dl) e le indagini strumentali (ecografia, TC e scintigrafia paratiroidea), in associazione con i dati clinici, sostenevano l?ipotesi diagnostica, confermata poi all'esame istologico, di carcinoma paratiroideo. Il trattamento chirurgico è stato efficace determinando la normalizzazione dei livelli di calcio e PTH e conseguentemente la risoluzione della sintomatologia. A due anni dall'intervento il paziente non presenta segni certi di recidiva locale, ma sono stati evidenziati micronoduli polmonari di incerto significato patologico. Discussione e conclusione. Nessun indice clinico o bioumorale consente con certezza la diagnosi pre-operatoria di carcinoma paratiroideo. Solo l?esame istologico definitivo, con l?ausilio dell?immunoistochimica, dirime il dubbio diagnostico differenziando l?adenoma dal carcinoma. La chirurgia rappresenta l?unica forma di trattamento. La neoplasia tende a recidivare, dapprima localmente e tardivamente a distanza. Per tale motivo i pazienti devono essere sottoposti, dopo l?intervento chirurgico, ad uno stretto follow-up con dosaggio del PTH e della calcemia

Tecnica open versus TAPP nel trattamento dell’ernia inguinale. Nostra esperienza

Introduzione. L’utilizzo di nuovi tipi di protesi per la riparazione open e l’introduzione di tecniche laparoscopiche hanno apportato radicali cambiamenti nel trattamento delle ernie inguinali. Resta tuttavia controversa la scelta del tipo di approccio. Scopo di questo lavoro è stato quello di confrontare i risultati del trattamento dell’ernia inguinale con posizionamento di protesi per via open e quelli ottenuti con tecnica laparoscopica transaddominale preperitoneale (TAPP). Pazienti e metodi. Lo studio ha riguardato 584 pazienti, 532 uomini e 52 donne, di età compresa tra i 19 e gli 86 anni, dei quali 332 (56,8%) operati con tecnica open e 252 (43,2%) per via laparoscopica con tecnica TAPP. Sono stati analizzati nei due gruppi tempi operatori, complicanze, recidive e ripresa dell’attività lavorativa. Il follow-up era da 1 anno fino a 10 anni. Risultati. La durata media dell’intervento è stata di 71 minuti per il gruppo open e di 92 minuti per il gruppo TAPP. Non si sono avute complicanze intraoperatorie. Il 4,5% dei pazienti del gruppo open ha presentato complicanze postoperatorie rispetto al 3% del gruppo TAPP. Il tasso di recidive è risultato inferiore all’1% nei due gruppi (in particolare, 0,6% per la riparazione open e 0,4% per quella laparoscopica). Il tempo medio alla ripresa dell’attività lavorativa è risultata nettamente a favore del gruppo TAPP (9,8 giorni) rispetto a quello open (13,4 giorni). Conclusioni. Il nostro studio dimostra fattibilità, efficacia e sicurezza della tecnica laparoscopica TAPP nel trattamento delle ernie inguinali in alternativa alla chirurgia convenzionale. L’esperienza del chirurgo e la learning curve sono fattori determinanti nella riduzione dei tempi operatori e della percentuale di complicanze e recidive

Cancer stem cells as functional biomarkers

According to the American Association of Cancer Research (AACR), a Cancer Stem Cell is a cell within a tumor that possesses the capacity to self-renew and to cause the heterogeneous lineages of cancer cells that constitutes the tumor [1]. Cancer Stem Cells (CSCs) are involved in the metastatic process, in the resistance to therapeutic treatments of many types of human cancers and consequently in the onset of recurrences. Numerous translational studies have been conducted to understand CSC characteristics and evaluate association between CSC-related biomarkers and clinical outcomes. The CSC theory can explain also a tumor relapse after that a tumor has been completely surgically removed (R0 macroscopical zero residual resection) or after an apparently complete response to chemoteraphy. CSCs, in fact, showed a marked ability to reduce intracellular accumulation of chemotherapic agents by active drug extrusion, increased chemoresistance and survival, as well as elevated membrane transporter activity. In addition, it is possible that these cancer stem cells may nest in the "secured" (niche) sites of our body, where they may remain undisturbed for a long time, even years, until a stimulus arrives to awaken them, causing the disease to resume. CSCs, in fact, are able to use a variety of cellular pathways to survive to anticancer treatments. More recently CSCs have been described in several solid tumors, expressing specific biomarkers. Another field of research should be focused on the realization of diagnostic instruments to follow up patients after R0 surgical resection or after a complete response for an early detection and management of relapse and metastasis

Reinterventi in chirurgia tiroidea: contributo casistico e revisione della letteratura

L'obiettivo di questo studio è di valutare la percentuale di complicanze nei reinterventi per patologia tiroidea e di individuare la metodologia di prevenzione delle stesse. Presentiamo la nostra casistica di 622 pazienti sottoposti ad intervento chirurgico per patologia tiroidea dal gennaio 2000 al settembre 2007. Di questi, 76 erano reinterventi per recidiva. Gli interventi di prima istanza nei rioperati erano: enucleoresezione in 9 (12.9%), lobectomia in 43 (55.5%), lobectomia più istmectomia in 7 (9.3%), tiroidectomia subtotale in 17 (22.2%). L’esame istologico definitivo deponeva per: iperplasia nodulare in 67 casi (88.15%), carcinoma papillifero in 4 casi (5.26%), tiroidite di Hashimoto in 2 casi (2.63%), adenoma follicolare in 1 caso (1.32%) e carcinoma follicolare in 2 casi (2.63%). Nei reinterventi si sono avute come complicanze maggiori: una (1.3%) sezione del nervo laringeo ricorrente, ricostruito con tecnica microchirurgica nello stesso atto operatorio; una (1.3%) insufficienza respiratoria acuta all’estubazione con paralisi delle corde vocali in adduzione ed integrità dei nervi ricorrenti verificata e documentata in occasione dell’immediato reintervento per il confezionamento della tracheostomia. Negli interventi di prima istanza si è avuto, invece, 1 caso (0.18%) di paralisi monolaterale di una corda vocale con dispnea lieve, stridore laringeo e disfonia. L'ipoparatiroidismo temporaneo (Ca<8mg/dl) si è avuto nel 47.3% dei pazienti sottoposti a reintervento e nel 45.2% dei pazienti sottoposti a tiroidectomia di prima istanza. Non si è avuto nessun caso di ipoparatiroidismo definitivo. Questo studio documenta che i reinterventi in chirurgia tiroidea possono essere realizzati con minima morbilità con un’accurata tecnica operatoria

Endoscopical En Bloc Resection of a Large Duodenal Adenoma with Focal High Dysplasia

Endoscopic mucosal resection is a potential alternative to surgery when submucosal invasion and lymph node involvement are excluded. We describe an en bloc resection of a large, focal, high-grade tubulovillous nonampullary adenoma of duodenal wall using hydroxypropyl methylcellulose as a lifting agent. © 2011 The Society for Surgery of the Alimentary Tract

Use of the circular compression stapler and circular mechanical stapler in the end-to-side transanal colorectal anastomosis after left colon and rectal resections A single center experience

The aim of our study was to compare the efficacy of the circular compression stapler and the circular mechanical stapler in transanal colorectal anastomosis after left colectomy or anterior rectal resection. We performed a retrospective analysis of 10 patients with disease of the, sigmoid colon or rectum (carcinoma or diverticular disease) who underwent left colectomy or anterior rectal resection with end-to-side transanal colorectal anastomosis. A follow-up was planned for all patients at 1, 3 and 6 months after surgery and the anastomosis was evaluated by colonoscopy at 1 year. In all patients an end-to-side transanal colorectal anastomosis was performed using a circular compression stapler (CCS group) or circular mechanical staplers with titanium staples (CMS group). The mean distance of the anastomosis from the anal margin was 6.4 ± 1.5 cm in the CCS group and 18.2 ± 11.2 cm in the CMS group. All patients in the CCS group expelled the ring after a mean time of 8.2 postoperative days. At 12 months colonoscopy revealed that all CCS patients had a satisfactory anastomosis with mean size of the colic lumen at the level of anastomotic line of 26.3 mm. In our experience the circular compression stapler a valuable alternative to the circular mechanical stapler for the creation of transanal colorectal anastomosis, in line with the relevant literature

Laparoscopic diagnosis and treatment of diaphragmatic Morgagni hernie. Case report and review of the literature

BACKGROUND: Morgagni's hernia is a rare and congenital type of diaphragmatic hernia. The majority of these are asymptomatic and diagnosed incidentally during evaluation or treatment for other conditions. When diagnosis is made surgery is mandatory. The Authors report the laparoscopic repair of small Morgagni hernia, followed by review of the literature. MATERIALS AND METHODS: A case of 55-year-old woman complaining a sensation of tightness in her chest, but especially an oppressive epigastric pain with episodes of fainting fit and breathless is described. The definitive diagnosis was confirmed by laparoscopy. The hernia was repaired laparoscopically using a mesh fixed by hernia stapler after excision of the sac. RESULTS: In the postoperative patients has presented an episode of heart condition due to pericarditis treated pharmacologically. The patient was discharged on the seventh postoperative day symptom-free. CONCLUSIONS: Laparoscopic technique must be considered as a first line approach for the treatment of Morgagni hernia, easy and safe by carry out. We recommend do not excise hernia sac, even if small, and particular cure in the use of the mesh fixed by metal staples