Francesco Gabrielli

Hemorrhoidectomy with posterior perineal block: experience with 400 cases.

PURPOSE: The aim of this study was to evaluate the advantages and feasibility of hemorrhoidectomy using regional anesthesia (posterior perineal block). METHODS: From March 1994 to December 1998 we performed 400 hemorrhoidectomies with regional anesthesia in an overnight-stay regimen in our department (Colo-Rectal Unit). Posterior perineal block involves anesthesia of the deep plains (infiltration of the inferior hemorrhoidal nerves, the posterior branch of the internal pudendal nerves, and the anococcygeal nerves) and anesthesia of the superficial plains (block of the inferior gluteal nerves and of perineal branches of minor nerves from the sacral plexus). RESULTS: Posterior perineal block was always effective; optimal to satisfactory intraoperative analgesia was obtained in 379 patients (95.2 percent), whereas in 17 cases (4.2 percent) intravenous analgesic drugs were administered. No conversion to general anesthesia was needed. Urinary retention was 7.8 percent. In our study most of patients (70 percent) reported no pain at all for five to ten hours. Ninety-two percent of patients were discharged in the first 24 hours. CONCLUSIONS: Posterior perineal block allows the surgeon to perform radical hemorrhoidectomies in an overnight-stay regimen with safe and effective intraoperative and postoperative analgesia, sphincter relaxation, and low incidence of urinary retention. Experience of the surgeon combined with careful surgical handling are of great importance for success in this technique.

Day surgery for mucosal-hemorrhoidal prolapse using a circular stapler and modified regional anesthesia.

PURPOSE: In 1993, prolapse reduction using the circular stapler for the treatment of hemorrhoidal disease was proposed. The procedure is characterized by minimal postoperative pain. In this study we evaluated the above technique using regional anesthesia to identify the advantages and feasibility of stapled hemorrhoidectomy, with special focus on the efficacy of same-day discharge. METHODS: From December 1997 to November 1999, we performed 70 consecutive reduction corrections of mucosal hemorrhoidal prolapse using the circular stapler with regional anesthesia (a technical modification of Martis posterior perineal block). Our series included 41 males and 29 females with a mean age of 43.4 (range, 25–74) years. Three patients were affected by second-degree hemorrhoids and 67 by third-degree hemorrhoids. RESULTS: Sixty-two patients were discharged three hours after the operation in good general condition and without pain, whereas eight patients were discharged the day after for early complications, consisting of two cases of early bleeding, three cases of urinary retention, and three cases of persistent severe pain requiring prolonged medical treatment. CONCLUSION: Our study shows that, in selected cases, it is possible to perform day surgery for patients with hemorrhoidal disease using a circular stapler device when combined with regional anesthesia.

The problem of pain after day-surgery haemorrhoidectomy

Abstract A total of 185 patients underwent day surgery haemorrhoidectomy with postoperative discharge after 24 h. An open technique (Milligan-Morgan) was adopted in 177 cases (97.8%) and a closed technique (Ferguson) in 8 cases (2.2%). In all cases, anaesthesia was achieved by the posterior perineal block: effective analgesia was obtained in 52.4% of the cases (very good and good analgesia) and postoperative analgesic effectiveness reached 5–10 h in most patients (49.2%), while in 9.2% of the cases analgesia was effective for up to 15 h or over. Innervation complexity and early wound stimulation make a painless haemorrhoidectomy impossible. It was not found that any particular surgical technique was superior to another. No evident advantages could be found in closed haemorrhoidectomies or laser/diathermic dissection nor was routine internal sphincterotomy found useful. Pain control was mainly entrusted to the action of pharmaceutical agents. In the operating theatre, the posterior perineal block can be followed by long term local anaesthetic or NSAIDs infiltration of muco-cutaneous wounds. During the postoperative period, lasting 30 days, pain assessment is not an easy task but this can be performed by Graphic Rating Scale. Pain at rest was moderate to acute during week 1 in 64.3% of the cases, while being light or absent in 35.7%. By week 2, pain had become moderate to acute in 29.2% of the patients, being light or absent in 70.8%. Finally, by week 3, only 10.8% of the patients reported moderate to acute pain (and this was due to complications ensuing such as haemorrhage or stenosis). Pain intensity increased at defecation, with 86% of the patients reporting acute moderate pain in week 1. A more gradual reduction of pain at evacuation was noted in later weeks compared to that at rest. Only in 2.7% of the cases did we have to resort to major analgesia during the first 24 h. In all other cases, NSAIDs (Ketorolac) sufficed with i.m. injections of 30 mg up to three times a day before discharge and 10 mg orally up to three times a day once the patient had returned home. Effective anaesthesia, competent surgery, a close follow up and regularly administered minor analgesics provide effective postoperative pain control after day surgery haemorrhoidectomy. As a result, the operation is no longer feared, as next to normal physical activity was reported towards the end of week 1 in 94.1% of the cases. Most patients expressed full satisfaction with their treatment 30 days after surgery.

Left-sided pancreatic incidentalomas treated with laparoscopic approach: a report of 20 cases

BackgroundThe diffusion of cross-sectional imaging has recently permitted the detection of an increasing number of incidentalomas localized in the distal pancreas.Currently, there are no studies in the literature exploring the laparoscopic approach as treatment for left-sided pancreatic incidentalomas.Methods and resultsWe report a series of 20 incidentalomas localized in the body and tail of the pancreas treated with laparoscopic surgery over the period 2010–2014. The incidental masses of our series included a great variety of histotypes and a relevant proportion of malignant lesions. In two cases, the laparoscopic procedures were converted to open surgery. No postoperative death was observed. The postoperative pancreatic fistula rate was 20xa0%, and the new-onset diabetes rate was 25xa0%.ConclusionsLeft-sided pancreatic incidentalomas in patients with minor comorbidities can be safely treated with laparoscopic approach. Only clinical trials will confirm whether laparoscopic surgery is an effective treatment for malignant lesions.

An indeterminate mucin-producing cystic neoplasm containing an undifferentiated carcinoma with osteoclast-like giant cells: a case report of a rare association of pancreatic tumors

BackgroundOnly few case reports of mucinous cystic pancreatic neoplasm containing an undifferentiated carcinoma with osteoclast-like giant cells have been described in the literature. In the majority of cases this unusual association of tumors seems related to a favorable outcome. We present the second case of an indeterminate mucin-producting cystic neoplasm containing an area of carcinoma with osteoclast-like giant cells. The specific features of the two histotypes and the rapid course of the disease make our clinical case remarkable.Case presentationA 68xa0year old female came to our attention for a pancreatic macrocystic mass detected with ultrasonography. Her past medical history was silent. The patient reported upper abdominal discomfort for two months; nausea, vomiting or weight loss were not reported. Physical examination revealed a palpable mass in the epigastrium; scleral icterus was absent. Cross-sectional imaging showed a complex mass of the neck and body of the pancreas, characterized by multiple large cystic spaces separated by thick septa and an area of solid tissue located in the caudal portion of the lesion. The patient underwent total pancreatectomy with splenectomy. Pathological examination revealed a mucinous cystic neoplasm with a component of an undifferentiated carcinoma with osteoclast-like giant cells. Because of the absence of ovarian-type stroma, the lesion was classified as an indeterminate mucin-producing cystic neoplasm of the pancreas. The immunohistochemical studies evidenced no reactivity of osteclast-like giant cells to epithelial markers but showed a positive reactivity to histiocytic markers. Numerous pleomorphic giant cells with an immunohistochemical sarcomatoid profile were present in the undifferentiated carcinoma with osteoclast-like giant cells. A rapid tumor progression was observed: liver metastases were detected after 4xa0months. The patient received adjuvant chemotherapy (Gemcitabine) but expired 10xa0months after surgery.ConclusionOur case confirms that the presence of a solid area in a cystic pancreatic tumor at cross-sectional imaging should raise a suspicion of malignant transformation. The lack of ovarian-type stroma in a pancreatic mucinous cystic neoplasm and the presence of pleomorphic giant cells in an undifferentiated carcinoma with osteoclast-like giant cells could be a marker of a poor prognosis.

Urgent pulmonary lobectomy for blunt chest trauma: report of three cases without mortality.

BACKGROUNDnThe majority of patients with severe blunt chest trauma is successfully treated with supportive measures and thoracostomy tube; only few cases need urgent thoracotomy. Lung-sparing techniques are treatments of choice but major pulmonary resections are necessary in case of injuries involving hilar vessels or bronchi. Currently the mortality associated with pulmonary lobectomy performed for chest trauma is 40%.nnnMETHODSnOver a 2-year period [2013-2014], 210 patients with chest trauma were hospitalized at our Institution. Mechanism of injury was blunt in 204 (97.1%) patients and penetrating in 6 (2.9%). In 48 (22.8%) patients was necessary a ventilatory support and 37 (17.6%) patients were treated with thoracostomy tube. Nineteen (9%) patients needed urgent thoracotomy: 4 (1.9%) cases for penetrating injury and 15 (7.1%) cases for blunt trauma. Three (1.4%) patients treated with urgent thoracotomy required concomitant laparotomy for intra-abdominal injuries. The overall mortality rate was 1.4%.nnnRESULTSnWe report three cases of urgent lobectomies for chest trauma without mortality and with postoperative complete restoration of respiratory function. The anatomical lobectomies were performed for: massive hemothorax with bronchial disruption, expanding pulmonary hematoma with hypovolemic shock, and massive hemothorax in deep parenchymal laceration.nnnCONCLUSIONSnMortality rate after major pulmonary resections for trauma is very high and increases with the presence of multivisceral injuries, the severity of hypovolemic shock and extent of lung resection. Anterolateral thoracotomy was the approach employed in case of cardiac arrest. In hypovolemic patients a posterolateral incision with a double lumen intubation was performed. The absence of mortality in this series may be related to the prompt diagnosis, short operative time and absence of associated severe neurological or abdominal injuries.

Circumferential anal giant condyloma acuminatum: a new surgical approach.

INTRODUCTION: Perianal giant condyloma acuminatum is a rare clinical condition related to human papillomavirus infection and characterized by a circumferential, exophytic, cauliflower-like mass with an irregular warty surface localized in the anal region. TECHNIQUE: A circular incision with a diathermocoagulator was performed on macroscopically healthy skin, 1 cm from the margin of the lesion. The dermis was divided from the subcutaneous tissue. This way, a mucocutaneous cylinder including the whole lesion was obtained. A median radial incision was carried out to open the cylinder at its front. A progressive circumferential section on healthy mucosa (≈1 cm above the margin of the lesion) by means of a radiofrequency dissector allowed for the complete removal of the mass. The healthy mucosa of the anal canal was pulled out by Allis forceps and was sutured to the external margin of the internal sphincter with single layer of Vicryl (polyglactin 910) 2-0 sutures. RESULTS: Two months after surgery, no findings of anal stenosis or mucosal ectropion were reported. At the 1-year follow-up there was no recurrence of condylomatosis in any of the 3 cases. CONCLUSIONS: Our procedure seems simpler to perform when compared with other techniques and reduces hospital stay and complications such as anal stenosis and mucosal ectropion.

Surgical Management of Full-Thickness Rectal Prolapse in the Elderly Patient

The incidence of full-thickness rectal prolapse is 1% in patients over 65 years of age. Risk factors are multiparity, previous pelvic surgery, and neurological or psychiatric disorders. IBS, constipation, and chronic straining are comorbidity factors. Symptoms and risk of complications are indications for surgical treatment. Among abdominal operations, ventral rectopexy recently seems to offer the best long-term results. Recurrence rate less than 3–4%, a net improvement of continence, is in up to 80–90% of cases; compared with traditional rectopexies, a greater improvement in constipation and a reduced risk of postoperative constipation are observed. Perineal procedures (Altemeier’s proctosigmoidectomy) are less demanding on the patients and are still the favorite technical choice in the elderly, mostly in high-risk patients. Morbidity and mortality are low and postoperative recovery is faster. If the technique is correctly performed, there seems to be no statistically significant difference in recurrence rate between abdominal and perineal procedures. However, in the last few years, there is a new emerging trend for a wider use of laparoscopic ventral rectopexy also in geriatric low-risk patients.

Streptococcus agalactiae infective endocarditis complicated by multiple mycotic hepatic aneurysms and massive splenic infarction: a case report

BackgroundThe burden of disease caused by Streptococcus agalactiae has increased significantly among older adults in the last decades. Group B streptococcus infection can be associated with invasive disease and severe clinical syndromes, such as meningitis and endocarditis.Case presentationWe present the case of a 56-year-old man who developed multiple mycotic aneurysms of the right hepatic artery and massive splenic infarction as rare complications of Streptococcus agalactiae infective endocarditis. The patient underwent urgent right hepatic artery ligation and splenectomy. The postoperative course was complicated by an episode of hemobilia due to the rupture of a partially thrombosed mycotic aneurysm into the biliary tree. Thus, selective radiological embolization of the left hepatic artery branches was necessary.ConclusionTo our knowledge, this is the first case reported of infected aneurysms of visceral arteries caused by Group B streptococcus infection. Clinical and laboratory findings were non-specific, while imaging features with computed tomography scan and angiography were highly suggestive. In our case, early recognition, culture-specific intravenous antibiotics and urgent surgical treatment combined with interventional radiology played a decisive role in the final result.

Big anal skin tags? What is this?

A hard and bleeding anal and perianal mass stenotized the anus and required left‐sided colostomy. Incisional biopsy showed a moderately differentiated spiniocellular carcinoma. Chemoradiotherapy treatment alone reduced significantly the mass.