C Nigro

Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease

BACKGROUND The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure. METHODS A total of 260 patients with sacrococcygeal pilonidal disease were assigned randomly to undergo Limberg flap procedure or tension-free primary closure. RESULTS Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure (P = .0793). Surgical time for primary closure was shorter. Wound infection was more frequent in the primary closure group (P = .0254), which experienced less postoperative pain (P < .0001). No significant difference was found in time off from work (P = .672) and wound dehiscence. Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group (P = .153). CONCLUSIONS Our results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.

Randomized clinical trial of LigaSure™ and conventional diathermy haemorrhoidectomy†

The aim of this randomized prospective trial was to compare LigaSure™ and conventional diathermy haemorrhoidectomy.

Dermoid cyst of the pancreas: presentation and management

BackgroundDermoid cyst of the pancreas is a benign, well-differentiated, extremely rare germ cell neoplasm. Published data indicate that differential diagnosis of cystic lesions of the pancreas is challenging and although ultrasonography, computed tomography and magnetic resonance may be useful, radiological findings are often inconclusive and the diagnosis is intraoperative. We report a case of a dermoid cyst of the tail of the pancreas intraoperatively diagnosed and successfully treated with left pancreatectomy. Further, characteristics, preoperative detection and differential diagnosis of this rare pathology are also discussed.Case presentationThis report documents the findings of a 64-year-old male presenting with a well defined echogenic pancreatic mass on ultrasonography. Computerized Tomography (CT) showed a 5 cm cystic tumor arising from pancreatic tail and Magnetic Resonance Imaging (MRI) suggested a tumor extension to the middle side of the stomach without defined margins. A left pancreatectomy was performed. On surgical specimen, histological evaluation revealed a dermoid cyst of the tail of the pancreas measuring 8.5 × 3.0 cm.ConclusionGiven the benign nature of the dermoid cyst, surgical resection most likely represents the definitive treatment and cure. In addition, resection is indicated in consideration of the difficulty in diagnosing dermoid cyst preoperatively. However, endoscopic ultrasound and fine needle aspiration cytology have recently been shown to be effective, safe, reliable and cost-saving preoperative diagnostic tools. Therefore, until more cases of dermoid cyst are identified to further elucidate its natural history and improve the reliability of the preoperative diagnostic tools, surgical resection should be considered the standard therapy in order to exclude malignancy.

End-to-end versus end-to-side stapled anastomoses after anterior resection for rectal cancer.

Sphincter‐saving procedures for resection of mid and, in some cases, of distal rectal tumors have become prevalent as their safety have been established. Increased anastomotic leak rate, associated with the type of anastomosis and the distance from the anal verge, has been reported. To compare surgical outcomes of end‐to‐end and end‐to‐side anastomosis after anterior resection for T1–T2 rectal cancer.

Botulinum toxin for recurrent anal fissure following lateral internal sphincterotomy.

The aim of the study was to evaluate the efficacy of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy.

Whitehead's hemorrhoidectomy. A useful surgical procedure in selected cases

Abstract. At the present time Milligan-Morgans operation is the most diffusely employed and is widely considered to be the most effective of the various surgical techniques for the treatment of hemorrhoids. In this study we report our experience with Whiteheads radical hemorrhoidectomy. In a 5-year period, 1450 patients with hemorrhoids were treated at our Coloproctologic Unit. We routinely carry out the Milligan-Morgan operation. Nevertheless, in 26 patients the Milligan-Morgan operation was judged to be impossible to perform, in that the prolapsed hemorrhoids were completely irreducible and it was not possible to distinguish and separate the three piles. These patients thus underwent Whiteheads radical hemorroidectomy. All the patients who underwent Whiteheads operation were discharged within the fifth post-operative day. No episodes of incontinence were observed in any patient. The patients were followed for three years after the operation. In only one case did we verify an anal substenosis three months after the operation, which resolved after the use of anal dilators for one month. The stenosis did not recur in the course of follow-up. There were no cases of mucosal ectropion. In conclusion, the type of hemorrhoidectomy which a surgeon performs is primarily based on the surgeons experience and training. Nevertheless, a competently performed Whiteheads hemorrhoidectomy can give satisfying results. These results are explained by improved knowledge of the anatomy of the anal region and a more accurate surgical technique. On the basis of our experience we believe that Whiteheads hemorrhoidectomy still has its place in selected cases with precise indications.

Evaluation of clinical, laboratory and morphologic prognostic factors in colon cancer

BackgroundThe long-term prognosis of patients with colon cancer is dependent on many factors. To investigate the influence of a series of clinical, laboratory and morphological variables on prognosis of colon carcinoma we conducted a retrospective analysis of our data.MethodsNinety-two patients with colon cancer, who underwent surgical resection between January 1999 and December 2001, were analyzed. On survival analysis, demographics, clinical, laboratory and pathomorphological parameters were tested for their potential prognostic value. Furthermore, univariate and multivariate analysis of the above mentioned data were performed considering the depth of tumour invasion into the bowel wall as independent variable.ResultsOn survival analysis we found that depth of tumour invasion (P < 0.001; F-ratio 2.11), type of operation (P < 0.001; F-ratio 3.51) and CT scanning (P < 0.001; F-ratio 5.21) were predictors of survival. Considering the degree of mural invasion as independent variable, on univariate analysis, we observed that mucorrhea, anismus, hematocrit, WBC count, fibrinogen value and CT scanning were significantly related to the degree of mural invasion of the cancer. On the multivariate analysis, fibrinogen value was the most statistically significant variable (P < 0.001) with the highest F-ratio (F-ratio 5.86). Finally, in the present study, the tumour site was significantly related neither to the survival nor to the mural invasion of the tumour.ConclusionThe various clinical, laboratory and patho-morphological parameters showed different prognostic value for colon carcinoma. In the future, preoperative prognostic markers will probably gain relevance in order to make a proper choice between surgery, chemotherapy and radiotherapy. Nevertheless, current data do not provide sufficient evidence for preoperative stratification of high and low risk patients. Further assessments in prospective large studies are warranted.

Prolapse and hemorrhoids: advances and insights in treatment

To the Editor—We read with great interest the review of randomized, controlled trials comparing stapled hemorrhoidopexy to conventional hemorrhoidectomy by Drs. Tjandra and Chan. In this large review of 25 randomized clinical trials on 1,918 patients, comparing the outcome of stapled hemorrhoidopexy with that of the conventional technique, stapled hemorrhoidopexy is recommended as safe, effective, reproducible procedure with better short-term outcome than conventional technique. In particular, the authors underlined that stapled hemorrhoidopexy is characterized by reduction of postoperative pain and bleeding, faster gastrointestinal and functional recovery, earlier discharge from hospital, and minimal wound care with greater patient satisfaction compared with conventional hemorrhoidectomy. The long-term results of the two procedures are similar. Conversely, Jayaraman et al., in the Cochrane Database System Review about stapled vs. conventional surgery for hemorrhoid treatment, stated that if hemorrhoid recurrence and prolapse are the most important clinical outcomes, the Milligan-Morgan open hemorrhoidectomy remains the standard, given that stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and prolapse. Furthermore, as affirmed by Drs. Tjandra and Chan, several trials included in the review are sample limited and not blinded, and the follow-up often is short-term and only in a few trials it is longer than two years. Regarding the effectiveness of hemorrhoidopexy, the stapled mucosectomy is best suited for Grades 2 or 3 hemorrhoids, whereas its efficacy in patients with fourthdegree hemorrhoids is still controversial. Different randomized trials, including patients with fourth-degree hemorrhoids, showed worse results after the stapled technique than after the conventional technique. Moreover, defecation disturbances, such as urgency, were observed after stapled procedure. In fact the consensus position paper about stapled hemorrhoidopexy established that this possibility should be discussed in the informed consent signed by the patient. In a recent French, randomized, multicenter trial of stapler hemorrhoidopexy vs. Milligan-Morgan procedure an overall urgency rate of 12 percent and a overall rate of continence impairment of 10 percent after surgery was reported. In addition, as recently underlined by Ortiz, taking into account the significant variation in the distance of the stapler line above the dentate line, it seems that the technique is not so easily reproducible as previously affirmed. Besides this, in a previous systematic review of 15 trials recruiting 1,077 patients comparing conventional hemorrhoidectomy with stapled hemorrhoidopexy, Nisar and colleagues recommended conventional hemorrhoidectomy as the more effective cure compared with the stapled procedure. Stapled hemorrhoidopexy had a higher recurrence rate (P=0.008) at a minimum follow-up of six months. Furthermore, although the stapled procedure was associated with less postoperative pain, shorter hospitalization, and faster returns to work, studies in a daycase setting did not prove that stapled hemorrhoidopexy was more feasible than conventional hemorrhoidectomy. In contrast, several randomized trials showed that new devices, including ultrasonic scalpel and LigaSureTM (Valleylab, Boulder, Colorado, USA), have been successfully used to perform Milligan-Morgan operation as day-case hemorrhoidectomy, allowing reduction of postoperative pain, decrease of bleeding, fast wound healing, and quick return to work. In a recent randomized trial comparing the LigaSureTM procedure and stapled hemorrhoidopexy, Kraemer and co-workers found no difference in all major aspects analyzed. Postoperative pain scores (P=0.99), patient satisfaction (P=1), and self-assessment of activity (P=0.99) were almost identical in both groups of patients. Besides, a slightly favorable trend for LigaSureTM regarding ease of handling and outcome with fourth-degree piles was detected by the authors. In summary, surgical management of hemorrhoids has undergone extensive reevaluation given the introduction of several instruments including circular stapler,

Authors' reply: Botulinum toxin for recurrent anal fissure following lateral internal sphincterotomy (Br J Surg 2008; 95: 774–778)

component in this study or in the studies examined by the two meta-analyses. Incontinence following LIS is associated with either extensive division of IAS or inappropriate division of the EAS3. Meta-analysis indicated that incontinence following LIS is 2·3 per cent and, similarly to BTx injection, is mostly transient. We would advocate the use of EAUS and ARP in every female (because occult anal sphincter injury occurs in 35 per cent of normal vaginal deliveries and 80 per cent with forceps deliveries4), and men with recurrent symptoms following LIS, before considering further procedures. J. C. I. Singh, M. Davies, U. Khot, T. V. Chandrasekaran, N. D. Carr and J. Beynon Department of Colorectal Surgery, Singleton Hospital, Sketty, Swansea SA2 8QA, UK DOI: 10.1002/bjs.6399