C. C. Chung

Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: Ligation technique

AbstractPURPOSE: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy using Harmonic Scalpel™, bipolar scissors, and the conventional scissors excision–ligation technique. METHODS: Eighty-six patients with irreducible prolapsing piles were randomly assigned to receive 1) Milligan-Morgan hemorrhoidectomy using scissors excision–ligation technique or 2) bipolar scissors hemorrhoidectomy and Harmonic Scalpel™ hemorrhoidectomy. Neither the patient nor the independent assessor were aware of the technique used at operation. Patients were followed up at 4 and 12 weeks after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative hospital stay; 4) pain score; 5) pain expectation score; 6) date of first bowel movement; 7) number of pethidine injections; 8) number of dologesic tablets taken; 9) time off work or normal activity; 10) wound healing; 11) satisfaction score; and 12) postoperative complications, including anal stenosis and fecal or flatus incontinence. RESULTS: There was no difference among the three groups in the operation time, hospital stay, pain expectation score, day of first bowel movement, number of dologesic tablets taken, time off work or normal activity, wound healing, and satisfaction score. The complication rate also did not differ in the three groups. Both Harmonic Scalpel™ hemorrhoidectomy and bipolar scissors hemorrhoidectomy were superior to Milligan-Morgan hemorrhoidectomy in terms of reduced blood loss. Harmonic Scalpel™ hemorrhoidectomy had the best pain score when compared with bipolar scissors hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy, and patients required significantly less pethidine injection after Harmonic Scalpel™ hemorrhoidectomy than after Milligan-Morgan hemorrhoidectomy. Although the time required to return to work or normal activity remained similar, patients after Harmonic Scalpel™ hemorrhoidectomy had the best satisfaction score among the three groups. CONCLUSION: The study shows that Harmonic Scalpel™ hemorrhoidectomy is as good as bipolar scissors hemorrhoidectomy in terms of reduced blood loss but is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits are small, and the time off work or normal activity remains similar.

a Double-blind, Randomized Trial Comparing Ligasuretm and Harmonic Scalpeltm Hemorrhoidectomy

PURPOSEThe major problem after hemorrhoidectomy is postoperative pain. New techniques have been evolved to circumvent this problem. The present study was conducted to compare the outcomes of LigasureTM hemorrhoidectomy and Harmonic ScalpelTM hemorrhoidectomy.METHODSThis study was a double-blind, randomized controlled trial. Patients with Grade 3 and 4 hemorrhoids admitted for hemorrhoidectomy were selected and randomized into two groups: 1) LigasureTM hemorrhoidectomy or 2) Harmonic ScalpelTM hemorrhoidectomy. The primary outcomes measured were the analgesic requirement and the postoperative pain score (assessed by an independent assessor). Secondary outcome criteria included the operating time, blood loss, hospital stay, patient satisfaction score, and early and late complications.RESULTSForty-nine patients were randomized into two groups (LigaSureT 24, Harmonic ScalpelT 25). Two patients were lost to follow-up, leaving 47 patients (LigaSureT 24, Harmonic ScalpelT 23) available for final analysis. The age and gender distribution were comparable. The postoperative pain score (median 2.6 vs. 4.8, P < 0.001) and postoperative oral analgesic (Dologesicreg) requirement (median 5 vs. 13, P = 0.001) were significantly less in the LigaSureT group. The operating time (median 11 vs. 18 minutes, P < 0.001) was significantly less in the LigaSureT group. The hospital stay, patient satisfaction score, percentage of patients requiring pethidine injection, percentage of patients with first bowel movement on or before the first postoperative day, and complication rates were similar between the two groups.CONCLUSIONSLigasureTM hemorrhoidectomy reduces the postoperative pain and operating time compared to the Harmonic ScalpelTM hemorrhoidectomy. It is a safe, effective procedure for treating Grade 3 and 4 hemorrhoids

Prospective evaluation of laparoscopic total mesorectal excision with colonic J-pouch reconstruction for mid and low rectal cancers

Results of laparoscopic sphincter‐preserving total mesorectal excision and colonic J‐pouch reconstruction are few. The aim of this study was to examine outcomes after this procedure.

Stapled Hemorrhoidopexy vs. Harmonic Scalpel™ Hemorrhoidectomy: A Randomized Trial

PURPOSEA randomized trial was undertaken to evaluate and compare stapled hemorrhoidopexy with excisional hemorrhoidectomy in which the Harmonic Scalpel™ was used.METHODSPatients with Grade III hemorrhoids who were employed during the trial period were recruited and randomized into two groups: (1) Harmonic Scalpel™ hemorrhoidectomy, and (2) stapled hemorrhoidopexy. All operations were performed by a single surgeon. In the stapled group, the doughnut obtained was sent for histopathologic examination to determine whether smooth muscles were included in the specimen. Operative data and complications were recorded, and patients were followed up through a structured pro forma protocol. An independent assessor was assigned to obtain postoperative pain scores and satisfaction scores at six-month follow-up. Patients were also administered a simple questionnaire at follow-up to assess continence functions.RESULTSOver a 20-month period, 88 patients were recruited. The two groups were matched for age and gender distribution. No significant difference was identified between the two groups in terms of operation time, blood loss, day of first bowel movement after surgery, and complication rates. Despite a similar parenteral and oral analgesic requirement, the stapled group had a significantly better pain score (P = 0.002); these patients also had a significantly shorter length of stay (P = 0.02), and on average resumed work nine days earlier than the group treated with the Harmonic Scalpel™ (6.7 vs. 15.6, P = 0.002). Although 88 percent of doughnuts obtained in the stapled group contained some smooth muscle fibers, no association was found between smooth muscle incorporation and postoperative continence function, and as a whole the continence outcomes of the stapled group were similar to those after Harmonic Scalpel™ hemorrhoidectomy. Finally, at six-month follow-up, patients who underwent the stapled procedure had significantly better satisfaction scores (P = 0.001).CONCLUSIONStapled hemorrhoidopexy is a safe and effective procedure for Grade III hemorrhoidal disease. Patients derive greater short-term benefits of reduced pain, shorter length of stay, and earlier resumption to work. Long-term follow-up is necessary to determine whether these initial results are lasting.

Laparoscopy and its current role in the management of colorectal disease.

Objective  To evaluate the current place of laparoscopy in the management of colorectal disease.

TOWARDS PAINLESS COLONOSCOPY: A RANDOMIZED CONTROLLED TRIAL ON CARBON DIOXIDE‐INSUFFLATING COLONOSCOPY

Background:  Carbon dioxide (CO2) insufflation during colonoscopy was reported to reduce pain, but data are limited. The objective of this randomized controlled trial was to assess the effect of CO2 insufflation on pain during and after colonoscopy.

Endo‐laparoscopic approach versus conventional open surgery in the treatment of obstructing left‐sided colon cancer: Long‐term follow‐up of a randomized trial

We previously conducted a randomized trial comparing the endo‐laparoscopic approach (i.e. placing self‐expanding metallic stents followed by laparoscopic resection) and conventional open surgery in the treatment of obstructing left‐sided colon cancer. This study is a follow‐up of the previous randomized trial and aims to report the long‐term outcomes of the two groups.

Hand-assisted laparoscopic versus total laparoscopic right colectomy: a randomized controlled trial

Aim  Laparoscopic colectomy for colorectal cancer is associated with definite short‐term benefits, and is increasingly practised worldwide. The limitations of a pure laparoscopic approach include a relative lack of tactile feedback and long procedural time. Hand‐assisted laparoscopic surgery was introduced in an attempt to facilitate operation by improving the tactile sensation. To date, there is no consensus as to which approach is better. Herein we conducted a randomized controlled trial comparing hand‐assisted laparoscopic colectomy (HALC) with total laparoscopic colectomy (TLC) in the management of right‐sided colonic cancer.

Laparoscopic abdominoperineal resection revisited: are there any health–related benefits? A comparative study

BackgroundLaparoscopic colectomy is associated with less overall morbidity and improved survival for patients with colonic cancers. There are unfortunately limited clinical reports on laparoscopic abdominoperineal resection. We therefore designed this study to compare laparoscopic abdominoperineal resection with conventional open surgery, with emphasis on health–related issues from the patients’ perspective in order to justify its role in the management of low rectal or anal canal tumours.MethodsWe carried out a non–randomized, prospective comparative study on a cohort of patients who underwent either laparoscopic or open abdominoperineal resection between March 1994 and December 2003. Patient demographics, tumour characteristics, operative morbidity and mortality, as well as overall survival were considered. The standard endpoints of last follow–up date and deaths were used. Data was analyzed according to intention–to–treat principle.ResultsA total of 102 patients were recruited: 31 patients underwent conventional open abdominoperineal resection (OAPR) and 71 patients were treated laparoscopically. Patient demographics, median follow–up period, as well as tumour characteristics were similar between groups. The median operating time was similar among groups (145 min in laparoscopic group vs. 156 min in open group; p=0.62). Patients in the laparoscopic group had significantly less blood loss (p=0.01) and fewer requirements for blood transfusion (p=0.01). Despite similar overall morbidity, the laparoscopic group had a reduced incidence of abdominal wound infections (p=0.01) and chest infections (p=0.01). Overall survival was significantly better in the laparoscopic group (p=0.01).ConclusionsLaparoscopic abdominoperineal resection confers definite health–related benefits the over open approach in terms of reduced septic complications and fewer requirements for blood transfusion. It should be considered the procedure of choice for patients with low rectal or anal canal tumour in whom sphincter excision proved inevitable.

The outcome of laparoscopic colorectal resection in T4 cancer.

Aim  Laparoscopic surgery for locally advanced tumours with extramural involvement is still controversial. It is believed that laparoscopic excision of T4 cancers is technically difficult and may result in prolonged operative time, increased conversion rate, added postoperative morbidity, and suboptimal oncological clearance.