D. Kanellos

Usefulness of Lateral Internal Sphincterotomy in Reducing Postoperative Pain after Open Hemorrhoidectomy

The aim of the present study was to evaluate the effect of lateral internal sphincterotomy on pain after open hemorrhoidectomy. From 1998 to 2003, seventy-eight (78) patients with fourth-degree hemorrhoids were included in this prospective randomized trial. The patients were randomized into two equal groups of 39 patients. Patients from group I underwent Milligan-Morgan hemorrhoidectomy. Patients from group II, quite apart from Milligan-Morgan hemorrhoidectomy, underwent lateral internal sphincterotomy up to the dentate line, in the left hemorrhoidectomy wound. One surgeon from the Department, who did not know to which group the patients belonged, evaluated the postoperative course in all the patients. After the first bowel movement, there were three (7.7%) patients who did not experience any pain in the internal sphincterotomy group, while in the non-internal sphincterotomy group all patients experienced mild or moderate pain. There were also more patients who experienced excruciating pain in the non-internal sphincterotomy group than in the internal sphincterotomy group (25 vs. 18); these differences were statistically significant (p = 0.034). There was no significant difference in the Wexner Incontinence Scale between the groups (p = 0.228). The addition of lateral internal sphincterotomy to open hemorrhoidectomy seems to have a positive effect on reducing postoperative pain in a few patients, without affecting the postoperative complications rate.

Long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids: a prospective study with median follow-up of 6 years

BackgroundThe aim of our study was to assess our early and long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids.MethodsOur study covers the time period from 1998 to 2002 and consists of 56 consecutive patients (33 men) with fourthdegree haemorrhoids who underwent stapled haemorrhoidopexy.ResultsDuring the postoperative period, 6 patients (10.7%) experienced pain for 7–14 days, which was treated with oral analgesia. Ten patients (17.8%) experienced gas incontinence and two of them also reported soiling. The incontinence subsided within 3–4 weeks. Median follow-up was 72.1 months (range, 55–56 months). Recurrence of the haemorrhoidal disease occurred in 33 patients (58.9%). The overall reintervention rate was 42.8%, as 24 patients required excisional haemorrhoidectomy by the Milligan-Morgan technique at a later stage.ConclusionsStapled haemorrhoidopexy seems to be a safe, low-pain but ineffective technique for the treatment of fourth-degree haemorrhoids, as it is accompanied by high recurrence and reintervention rates in the long term.

Effects of steroid on the healing of colonic anastomoses in the rat

BackgroundThe aim of this experimental study was to evaluate the effects of steroid on colonic anastomosis in a rat model.MethodsForty female Wistar rats were randomised into two groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. In the rats of the control group 2 ml of solution 0.9% NaCl was injected once daily intraperitoneally perioperatively. Rats of the steroid group received intraperitoneally once daily, and on the same perioperative days, hydrocortisone (5 mg/kg body weight in 2 ml solution NaCl). All the rats were sacrificed on the 8th postoperative day and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded and anastomoses were graded histologically.ResultsDehiscence rate was significantly higher in the steroid group than in the control group (p<0.001). Mean bursting pressure was significantly lower in the steroid group compared to the control group (p<0.001). Colonic healing process assessed as inflammatory cell infiltration and collagen deposition was significantly lower in the steroid group than in the control group (p<0.001, p=0.03 respectively).ConclusionsPerioperative steroid treatment adversely affects healing of colonic anastomoses in the rat.

The healing of colon anastomosis covered with fibrin glue after early postoperative intraperitoneal chemotherapy.

AbstractBackgroundAfter colon resection for colonic cancer, the administration of antineoplastic agents may prolong survival by killing residual cancer calls and preventing metastasis, but may also slow anastomotic healing. This study was designed to determine the effects of 5-fluorouracil (5-FU) and leucovorin (LEV), injected intraperitoneally, on the healing of colonic anastomoses with or without fibrin glue (FG) covering.MethodsSixty rats were randomized to one of four groups. After resection of a transverse colon segment, an end-to-end sutured anastomosis was performed. Rats in the 5-FU+LEV and the 5- FU+LEV+FG groups received 5-FU+LEV intraperitoneally. The colonic anastomoses of the rats in the FG group and in the 5-FU+LEV+FG group were covered with fibrin glue. All rats were killed on postoperative day 8. Bursting pressure measurements were recorded and the anastomoses were examined macroscopically and histologically.ResultsThe leakage rate of the anastomoses was significantly different among groups. Specifically, the leakage rate was significantly higher in the 5-FU+LEV group (40%) than in the FG and in the 5-FU+LEV+FG groups where there were no leakages (p=0.017). The mean adhesion formation score was significantly higher in rats of the 5-FU+LEV group, compared to the control (p=0.023), the FG (p=0.006) and the 5-FU+LEV+FG (p=0.006) groups. Bursting pressures were significantly lower in the 5-FU+LEV group than in the other groups (p<0.001). Also, bursting pressures were significantly lower in the control group compared to the FG and 5-FU+LEV+FG groups (p<0.001). Rats in the 5-FU+LEV+FG group had significantly greater neoangiogenesis and fibroblast activity than those in the 5-FU+LEV group (p=0.025).ConclusionThe early intraperitoneal postoperative administration of 5-fluorouracil plus leucovorin impaired colonic wound healing. However, the application of fibrin glue prevented the deleterious effect of chemotherapy.

Prognostic significance of CEA levels and positive cytology in peritoneal washings in patients with colorectal cancer

Objective  The aims of this prospective study were to determine carcinoembryonic antigen (CEA) levels and incidence of cytology in peritoneal washings of patients with colorectal cancer, correlate the results with various histopathological factors and determine their significance as prognostic factors of the disease.

Long-term results after stapled haemorrhoidopexy for third-degree haemorrhoids.

BackgroundStapled haemorrhoidopexy (SH) is associated with low postoperative pain but, when performed for advanced piles, carries high recurrence rates. The aim of our study was to assess our long–term results after SH for third–degree haemorrhoids.MethodsA total of 126 consecutive patients (67 men and 59 women) with third–degree haemorrhoids underwent SH in our unit between 1998 and 2002. Of these, 120 (95.2%) were followed up in the outpatient department after a median interval of 61.5 months (range, 38–84 months).ResultsDuring the postoperative period, 7 patients (5.8%) experienced pain for 5–12 days, which was treated with oral analgesia. Seven patients (5.8%) experienced gas incontinence and one of them also reported soiling; the incontinence subsided within 2–8 weeks. Recurrence of the haemorrhoidal disease occurred in 8 patients (6.6%).ConclusionsSH is a safe, low–pain and, in the long–term, effective technique for the treatment of third–degree haemorrhoids.

Contribution of insulin-like growth factor I to the healing of colonic anastomoses in rats.

The aim of this experimental study was to investigate the contribution of insulin-like growth factor I (IGF)-I in the colonic healing process when injected intraperitoneally after colon resection. Forty male Wistar rats were used. Rats in the control group were injected with 3 mL of a solution of 0.9% NaCl intraperitoneally after the operation and on postoperative day 2, 4, and 6. Rats in the IGF-I group received recombinant human IGF-I in a dose of 2 mg/kg body weight intraperitoneally, immediately after the colonic anastomosis was performed and on postoperative day 2, 4, and 6. All rats were killed on postoperative day 7. The hydroxyproline tissue content was significantly higher in the IGF-1 group than in the control group. The bursting pressures were also significantly higher in IGF-1 group than in the control group. The weight change between the groups differed significantly; in the control group the average weight decreased about 5% postoperatively, while in the IGF-1 group the average weight increased about 6%. The average inflammatory cell infiltration score was significantly higher in the control group. Neoagiogenesis did not differ significantly between the two groups. The fibroblast activity differed significantly between the two groups, as the control group had significantly less fibroblasts compared to the IGF-1 group. In conclusion, IGF-I when given intraperitoneally stimulates the healing of colonic anastomoses in the rats. Further studies are required in order to determine whether this effect is dose related.

Progress in rectal cancer staging and treatment

Colorectal cancer poses a worldwide major health issue. Rectal cancer has somewhat distanced itself from colonic cancer as a different oncologic entity, due to differences in diagnosis and treatment. Several developments over the last years have improved screening, diagnostics, pre-operative therapy, surgical techniques and postoperative patient care. The multidisciplinary approach to rectal cancer, mainly through the co-operation of surgeons, oncologists and radiologists, seems to be one of the most important steps in the management of that disease.

Value of Carcinoembryonic Antigen Assay in Predicting Hepatic Metastases, Local Recurrence, and Survival After Curative Resection of Colorectal Cancer

PurposeWe measured carcinoembryonic antigen (CEA) levels in peripheral and portal venous blood, and bile from patients with colorectal cancer, to determine its role in predicting hepatic metastases, local recurrence, and survival.MethodsThe subjects were 73 patients who underwent curative surgery for colorectal cancer.ResultsThe median serum, bile, and portal CEA levels were significantly lower in 5-year survivors than in patients in whom hepatic metastases or recurrent disease subsequently developed. The CEA level in portal blood and bile was a good indicator of hepatic metastases, with sensitivity of 92% and 100%, respectively. However, the accuracy of any CEA measurement for predicting hepatic metastases, local recurrence, or 5-year survival did not exceed 70%.ConclusionsNone of these CEA measurements is accurate enough to be the basis of a management decision. Thus, we suggest that CEA measurement be used to assist in the prediction of a high risk of the development of hepatic secondaries and that these patients are followed up closely after curative resection.

Repair of parastomal hernia with the use of polypropylene mesh extraperitoneally

Parastomal hernia is the most frequent complication of colostomy. Many surgical techniques have been postulated and prosthetic surgery seems to represents the first-choice treatment. The aim of this study is to report the surgical treatment of 4 patients that developed parastomal hernia, 3–10 months after abdominoperineal excision of the rectum and permanent sigmoidostomy due to carcinoma of the rectum. The repair was made with the use of polypropylene mesh extraperitoneally. One case of limited skin necrosis occurred without any serious consequences. No recurrence has been recorded among the patients, up to this day (follow-up period: 36 months). In conclusion, the suturing of fascial defect and the use of polypropylene mesh extraperitoneally is effective in the treatment of parastomal hernia.