Edward Ramadan

Harmonic scalpel hemorrhoidectomy: preliminary results of a new alternative method

Abstract. Surgical treatment is considered to be the best therapeutic modality for severe hemorrhoidal disease. Different surgical methods of hemorrhoidectomy aim to decrease pain, bleeding, stenosis and discharge. The aim of this study was to evaluate the efficacy of harmonic scalpel hemorrhoidectomy. During a period of seven months, 54 consecutive patients with third- and fourth-degree hemorrhods were prospectively randomized for harmonic scalpel hemorrhoidectomy (HS) or Milligan-Morgan procedure (MM). These patients were examined at one, two, and six weeks after the operation. All patients had a lower gastrointestinal investigation prior to operation to exclude other colorectal pathologies. All patients had the same kind of preoperative preparation and analgesia during the postoperative course. Pain was assessed using a visual analog scale from 0 to 10. Patient satisfaction was defined as decrease or absence of symptoms and return to normal daily activities. HS groups included 29 patients, while the MM group had 25 patients. There as no difference between the groups in terms of age, gender, hemorrhoidal degree and indication for operation. The types of intra-operative anesthesia administered to the two groups were similar. Duration of surgery was significantly higher in the MM group (p<0.0001). Postoperative hospitalization was longer in the MM group (p<0.0001), and the pain degree was higher in MM group (p<0.0001). No significant difference was noted in the overall amount of analgesics used in the two groups at week 1, although it was significantly higher in the MM group 2 and 3 weeks after the operation. Early complication occurred more frequently in the MM group but overall the difference was not statistically significant. In conclusion, harmonic scalpel hemorrhoidectomy is virtually a bloodless operation with minimal tissue damage. It is associated with significant less postoperative pain and a fast return to normal activity.

Clozapine decreases rat brain dehydroepiandrosterone and dehydroepiandrosterone sulfate levels

We examined the influence of the atypical antipsychotic agent clozapine compared to haloperidol, on levels of dehydroepiandrosterone and dehydroepiandrosterone sulfate ester (both gamma-aminobutyric acid(A) (GABA(A)) receptor allosteric antagonists) in the rat cortex. i.p. injections of clozapine (5 and 15 mg/kg), but not haloperidol (1 mg/kg), for 8 days decreased rat brain cortical dehydroepiandrosterone and dehydroepiandrosterone sulfate levels. These findings support the role of neurosteroids and possibly GABA(A) receptor modulation in the mechanism of action of clozapine.

Rectal flap advancement – a simple and effective approach for the treatment of rectourethral fistula

Objective  Rectourethral fistula is a rare complication of prostatic surgery and other pelvic procedures. We report our experience of surgical repair of using a rectal advancement flap.

Silastic Ring Vertical Gastroplasty— Long-term Results and Complications

Background: Silicone ring vertical gastroplasty (SRVG) in some reports is associated with significant morbidity and a tendency to regain weight in the late postoperative period. The present study aims to evaluate our long-term results, along with early and late postoperative complications. Methods: The early and late postoperative complications of 300 patients undergoing SRVG and followed for an average of 3.2 years, were reviewed retrospectively .The pre- and post-operative weight and body mass index (BMI) were recorded in a subgroup of 131 patients with an average follow-up of 5.2 years. Results: Early postoperative complications occurred in 99 patients (33.1%), with mortality of one patient (0.3%).Vomiting was the most common late complication, occurring in 49.3%. Re-operation was performed in 19.7% of the patients, mostly for the repair of postoperative ventral hernia. Long-term results following SRVG showed a decrease in weight from 131 ± 25 kg to 94 ± 23.2 kg, and BMI decreased from 46.1 ± 8.1 kg /m2 to 32.9 ± 7.4 kg/m2. Excess body weight loss was 58.5 ± 39.8% . Conclusions: Most patients (76%) reported their satisfaction following SRVG. Long-term results revealed a significant and sustained weight loss, mild complications and low mortality rate.

Overexpression of cyclin D1 mRNA in colorectal carcinomas and relationship to clinicopathological features : An in situ hybridization analysis

Increased expression of a key cell cycle regulator, cyclin Dl, may have relevance to carcinogenesis and clinicopathological characteristics of some cancers. This study represents the first application ofin situ hybridization, ISH, to detect cyclin Dl mRNA in tissue sections from colorectal carcinomas. This approach was selected because of its unique potential to clarify whether increased expression of cyclin Dl mRNA correlates with clinical and pathological parameters. The ISH of a non-radioactive oligonucleotide probe (Biogenex) was immunocytochemically detected in paraffin embedded sections from biopsy or resection specimens. Tumors ranged from well to poorly differentiated, and from stages A, B, C, and D. Ten year survival data were available on the majority of patients. Intensity of tumor and background (smooth muscle) signals were independently scored from 0 to 3. Overexpressed cyclin Dl mRNA was seen in 86% of cases compared to back-ground. This frequency is similar to that reported for pancreatic carcinoma. The average signal intensity score in tumor foci was 1.9 with a background score of 0.05 (p < 001). All cases showed specific staining judged by the cytoplasmic localization and a tumor signal:background ratio > 1. Expression did not differentiate cancers based on grade, stage or survival (p>l), but did differentiate carcinoma and severe dysplasia from mild dysplasia. We conclude that ISH of cyclin Dl mRNA is an effective and relatively specific means of detecting activity of this gene in colonic neoplasms. The high frequency of overexpression implies that gene activity by itself is not likely to predict a tumor’s biological or clinical behavior. On the other hand, these data suggest that increased cyclin Dl gene activity may be an early event in colorectal carcinogenesis. They also are consistent with findings showing cyclin Dl is inducible by a variety of oncogene products.

Rectal Prolapse: A Possibly Underrecognized Complication of Anorexia Nervosa Amenable to Surgical Correction

Objective: Rectal prolapse is a complication of AN that may be more common than previously recorded experience would suggest. Method: In this report we document, for the first time, the association of anoxia nervosa (AN) and rectal prolapse in a series of three patients seen in the past three years. An extensive review of the literature using Medline over the period from 1966 to Jan 2000 failed to reveal any previous example of this association. Results and Conclusion: The finding could have significant health care implications if confirmed. It would suggest that patients with either the psychiatric or surgical problem may not be receiving the appropriate complementary referrals: psychiatrist to surgeon and vice versa. The importance of recognition of this association in anorectic patients is the availability of effective surgical therapy.

Brain neurosteroid changes after paroxetine administration in mice

Although it is known that selective serotonin reuptake inhibitors (SSRIs), as other antidepressants, elevate mood only after 3-4 weeks of treatment, the mechanism responsible for this delay is not understood. SSRIs have been demonstrated to alter the levels of neurosteroids such as allopregnanolone (THP) which possess anxiolytic and mood-elevating properties. We compared the effect of 9 and 21 days i.p. administration of paroxetine, a potent SSRI, on the synthesis of THP and its precursor, 5alpha-dihydroprogesterone (DHP), in the mouse cortex, hypothalamus and olfactory bulb. Cortex, olfactory bulb and hypothalamus synthesized levels of DHP were significantly raised after 9 days of paroxetine administration, whereas a significant rise in the THP synthesized level was observed only after 21 days of treatment. Peripheral synthesis of DHP, measured by the level in serum, significantly increased after 9 days, but reverted to normal values after 21 days. No increase was detected in serum THP levels either after 9 or 21 days treatment. Differences in peripheral and brain synthesis indicates independence in brain synthesis. The data indicate that paroxetine administration differentially increases [3H]DHP and [3H]THP content, depending on the duration of the treatment. Our results suggest that brain THP may be involved in the antidepressive and anxiolytic activity of paroxetine.

Chronic lithium treatment affects rat brain and serum dehydroepiandrosterone (DHEA) and DHEA-sulphate (DHEA-S) levels

Lithium (Li) is an established effective treatment for bipolar disorder. However, the molecular mechanism of its action is still unknown. Dehydroepiandrosterone (DHEA) and its sulphate ester (DHEA-S) are adrenal hormones also synthesized de novo in the brain as neurosteroids. Recent studies have suggested that DHEA has mood-elevating properties and may demonstrate antidepressant effects. 3(2)-Phosphoadenosine 5-phosphate (PAP) phosphatase is a novel Li-inhibitable enzyme involved in sulphation processes. In the present study we examined the impact of 10 d Li treatment on serum and brain DHEA and DHEA-S levels in rats. Our results show that Li administration lowered frontal cortex and hippocampus DHEA and DHEA-S levels, in line with our hypothesis assuming that Lis inhibition of PAP phosphatase leads to elevated PAP levels resulting in inhibition of sulphation and reduction in brain DHEA-S levels. Future studies should address the involvement of neurosteroids in the mechanism of Lis mood stabilization.

Long-Term Follow-Up and Factors Influencing Success of Silastic Ring Vertical Gastroplasty

Background: Careful selection of patients for the operation plays a major role in long-term results of silastic ring vertical gastroplasty. The objective of the current study is to identify predictive factors for the objective (excess weight loss) and subjective (satisfaction) success of silastic ring vertical gastroplasty (SRVG) for morbid obesity. Methods:Design: Retrospective cohort study. Setting: University hospital. Subjects: 300 patients of 450 who were operated on between 1984 and 1997. Follow-up time was 4.4 ± 2.3 years. Intervention: SRVG. Statistical Methods: Correlations, multi-linear regression model. Results: Average BMI (body mass index) loss: 13.6 ± 7.4 kg/m2, average excess weight loss was 67.4 ± 33.0%. Satisfaction rate: 81.3%. Correlation was found between objective parameters of successes and the satisfaction of the patient (p < 0.001). Excess weight loss was correlated to younger age (p < 0.005), pre-operative weight and BMI (p < 0.005, p < 0.01, respectively), and shorter follow-up (p < 0.001). Multiple linear regression model revealed that age and preoperative weight were independent vari ables and correlated to the excess weight loss after SRVG (R2 = 0.303, p < 0.01; R2 = 0.026, p < 0.05). Social support was correlated to satisfaction (p < 0.05). Conclusions: SRVG is an operation with high rates of objective and subjective success rate. Younger and heavier subjects will mostly enjoy SRVG in terms of excess weight loss. Patients who have social support have the most satisfactory emotional outcome.

Nodular lymphoid hyperplasia of the small bowel associated with two primary colonic adenocarcinomas

Abstract A patient presented with rectal bleeding and weight loss. On barium enema two space-occupying lesions, one in the cecum and the other in the right transverse colon, were demonstrated. He underwent right hemicolectomy. The surgical specimen demostrated diffuse nodular lymphoid hyperplasia (NLH) of the small intestine and two primary carcinomas of the colon, an association that to the best of our knowledge has not been previously described.