Gianpiero Gravante

Transanal hemorrhoidal dearterialization: a systematic review.

PURPOSE: Transanal hemorrhoidal dearterialization consists of a Doppler-guided ligation of the distal branches of the rectal arteries. The aim of this review is to assess the current evidence on dearterialization, establish the safety and efficacy of the technique, define its indications, and identify its possible advantages and limitations. METHODS: All published studies on dearterialization without language restrictions were reviewed systematically. Primary outcome measures were postoperative pain and hemorrhoidal recurrences. RESULTS: Seventeen articles including a total of 1,996 patients were analyzed. In general, the quality of the studies was low. Operating time ranged between 5 and 50 minutes. Hospital stay was one day for most patients, whereas the return to normal activities was between two and three days in most cases. Postoperative pain was present in 18.5% of patients. Three patients experienced significant postoperative hemorrhages. There were no other major complications. The overall recurrence rate was 9.0% for prolapse, 7.8% for bleeding, and 4.7% for pain at defecation. The recurrence rate at one year or more was 10.8% for prolapse, 9.7% for bleeding, and 8.7% for pain at defecation. When reported as a function of the hemorrhoidal grade, the recurrence rate was higher for fourth-degree hemorrhoids (range, 11.1–59.3%). CONCLUSION: Transanal hemorrhoidal dearterialization appears to be a potential treatment option for second-degree and third-degree hemorrhoids. Clinical trials and longer follow-up comparing it with other procedures used to treat hemorrhoids are needed to establish a possible role for this technique.

Long-term outcomes of stapled hemorrhoidopexy vs conventional hemorrhoidectomy: a meta-analysis of randomized controlled trials

OBJECTIVES To assess the long-term results of stapled hemorrhoidopexy (SH) compared with conventional hemorrhoidectomy (CH) and to define the role of SH in the treatment of hemorrhoids. DATA SOURCES Published randomized controlled trials of CH vs SH with a minimum clinical follow-up of 12 months were searched and selected in the MEDLINE, EMBASE, and Cochrane Library databases using the keywords hemorrhoid, stapl, and anopexy, without language restrictions. STUDY SELECTION Potentially relevant studies were identified by the title and the abstract, and full articles were obtained and assessed in detail. DATA EXTRACTION Studies were scored according to the presence of 3 key methodologic features of randomization, blinding, and accountability of all patients, including withdrawals, and the scores ranged from 0 to 5. Studies that received a score from 3 to 5 were considered high-quality studies, whereas those with a score of 2 or less were considered of low quality. A specifically designed data form was used to collect all relevant data, including details of the experimental design, patient demographics, technical aspects, outcome measures, and complications. DATA SYNTHESIS Fifteen articles met the inclusion criteria for a total of 1201 patients. Outcomes at a minimum of 1 year showed a significantly higher rate of prolapse recurrences in the SH group (14 studies, 1063 patients; odds ratio, 5.5; P < .001) and patients were more likely to undergo further treatment to correct recurrent prolapses compared with the CH group (10 studies, 824 patients; odds ratio, 1.9; P = .02). CONCLUSION Stapled hemorrhoidopexy is a safe technique for the treatment of hemorrhoids but carries a significantly higher incidence of recurrences and additional operations compared with CH. It is the patients choice whether to accept a higher recurrence rate to take advantage of the short-term benefits of SH.

Capsular contractures: a systematic review.

Background: The aim of this article was to review the current literature on capsular contractures, focusing in particular on the epidemiology, risk factors, cause, and treatment modalities, to provide the plastic surgeon with an up-to-date review of the current available evidence. Methods: A literature search was undertaken of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases. The search strategy was conducted using three groups of key words, with the first relating to the organ involved (breast), the second relating to the surgical procedure performed and related technical issues, and the third relating to the surgical complications. Potentially relevant articles were identified by means of the title and the abstract, and full articles were obtained and assessed in detail. Results: Only a few studies have included large enough sample sizes, were conducted in a prospective manner, were adequately randomized, and achieved adequate follow-up periods to obtain a true measure of rates of capsular contraction occurrence. Recent advances in molecular biology, microbiology, immunology, and basic pathology have outlined some of the mechanisms that underlie this phenomenon. Revision surgery remains the only effective treatment option available but is limited by its high associated risk of recurrences. No adequate preventative measures exist in practice, beyond the avoidance of risk factors. Conclusions: Although a great deal of progress has been made over the past few decades, the exact nature and contribution of molecular, immunologic, and microbiological factors remain unclear. It is hoped that future studies will focus on attempting to resolve some of the issues highlighted in this review.

Nanocrystalline silver: a systematic review of randomized trials conducted on burned patients and an evidence-based assessment of potential advantages over older silver formulations.

The aim of this meta-analysis was to collect data from randomized trials in burn patients and to analyze them with a meta-analytic approach to give a clear message of potential advantages of nanocrystalline silver (NC) versus older silver formulations (SS).A review of all-English prospective randomized trials that compared NC versus silver sulfadiazine or silver nitrate was conducted. Primary outcome was the evaluation of differences in the infection rate of burns. Secondary outcomes were the eventual differences in the pain experienced during medications, the length of hospitalization (LOS) and costs.Five articles that met the inclusion criteria were selected (n = 285 patients). The NC group had a significant lower incidence of infections compared with the SS group (9.5% vs. 27.8%, odds ratio: 0.14 [95% CI: 0.06–0.35]; &khgr;2 test, P < 0.001), with a 2.9-fold decrease of the risk. Not all studies investigated the pain during change of dressings, LOS and costs. However, when data were available, these showed lower costs (US

Infections of Breast Implants in Aesthetic Breast Augmentations: A Single-Center Review of 3,002 Patients

1533 per patient for the SS group and US

A Retrospective Analysis of 3,000 Primary Aesthetic Breast Augmentations: Postoperative Complications and Associated Factors

946 per patient for the NC group) and decreased pain values in the NC group (Hedges’ G: −1.44 [95% CI: −1.86/−1.01]; P < 0.0001), while contrasting results were obtained for LOS.Nanocrystalline silver is a relatively new product with a significant stronger antimicrobial activity compared with older formulations. Its long lasting properties reduce dressing change frequency and are probably responsible for the decreased pain and the minor costs experienced.

The Use of Hyalomatrix PA in the Treatment of Deep Partial-Thickness Burns

BackgroundA large retrospective analysis examined primary aesthetic breast augmentations to find specific factors that could favor or counteract the occurrence of infections.MethodsData were collected from the personal databases of two different surgeons at the Crown House Hospital, Oldbury, Birmingham, United Kingdom, from January 1999 to December 2004. All the patients who received primary aesthetic breast augmentation with or without associated mastopexy were recorded.ResultsA total of 3,002 women were reviewed. Infections were experienced by 33 patients (1.1%). The analysis showed that Mentor prostheses and local antibiotics both were protective against the occurrence of infections (p < 0.05). On the contrary, the use of drains significantly increased the risk fivefold (p < 0.05).ConclusionsThe incidence of infections in aesthetic breast augmentations is 1.1%, and Mentor prostheses, antibiotics in the pocket, and the use of drains seem associated with their occurrence.

Mechanical bowel preparation for colorectal surgery : a meta-analysis on abdominal and systemic complications on almost 5,000 patients

BackgroundA large retrospective analysis was performed on a homogeneous group of patients undergoing primary aesthetic breast augmentations to define complication rates and find associated factors.MethodsData were collected from the personal databases of two different surgeons working at the Crown House Hospital, Oldbury, Birmingham, United Kingdom. The period considered was January 1996 to December 2001. All patients who received primary breast augmentation with or without associated mastopexy for cosmetic purposes were recorded.ResultsA total of 3,002 women were included in the study. Hematomas were present in 46 patients (1.5%), infections in 33 patients (1.1%), breast asymmetries in 23 patients (0.8%), rippling in 21 patients (0.7%), and capsular contractures in 14 patients (0.5%). The multivariate analysis found that implant placement and the technique used for pocket creation were variables associated with complications (p < 0.05). Capsular contractures carried a progressive cumulative risk and, in our series, appeared 5 years after surgery. No association was found between contractures and hematomas or infections.ConclusionsThe overall incidence of complications in our series was relatively high (4.6%). Surgical placement of prostheses and the technique used for pocket creation were associated with complications. However, few patients required reoperation (1.6%), and the overall satisfaction rate was acceptable (visual analog score, 7).

Versajet hydrosurgery versus classic escharectomy for burn débridment: a prospective randomized trial.

Since 2001, Hyalomatrix PA (Fidia Advanced Biopolymers, Abano Terme, Italy) has been used in our center on pediatric burned patients as a temporary dermal substitute to cover deep partial-thickness burns after dermabrasion. This “bridge” treatment was adopted to remove necrotic debris (dermabrasion) and to stimulate regeneration in a humid and protected environment (Hyalomatrix PA). We present results obtained with this approach. On the third to fifth day after admission, dermabrasion was practiced on deep burned areas, which were covered with Hyalomatrix PA. Change of dressings was performed every 7 days. On day 21, those areas still without signs of recovery were removed with classic escharectomy and covered with thin skin grafts. We treated 300 patients. Sixty-one percent needed only one dermabrasion treatment, 22.3% (67 patients) more than one, and 16.7% (50 patients) the classic escharectomy. A total of 83% of patients healed within 21 days. Our study suggests that the combination of dermabrasion with a temporary dermal substitute could be a good and feasible approach for treatment of deep partial-thickness burns. Prospective randomized studies are now necessary to compare our protocol with the gold standard treatment of topical dressings.

Wound infections in aesthetic abdominoplasties: the role of smoking.

BackgroundSeveral studies concluded that mechanical bowel preparation (MBP) does not confer any advantage on reducing the anastomotic leak rate or wound infections. The aim of this meta-analysis was to review all prospective randomised controlled trials on the use of MBP before colorectal surgery in order to find differences in the rates of abdominal and systemic complications in view of recent published articles.MethodsReview of all randomised prospective trials compare MBP vs. non-MBP. Primary outcome measures were anastomotic leakages, abdomino-pelvic abscesses and postoperative ileus. Secondary outcomes were wound infections, extra-abdominal complications (urinary infections, pulmonary infections, deep venous thrombosis or pulmonary embolism, cardiac events), sepsis and mortality.ResultsTwelve articles met the inclusion criteria with 4,919 patients. The non-MBP group showed no significant increase of the anastomotic leakages (3.4% vs. 4.1%; p = NS) and wound infections (8.7% vs. 9.6%; p = NS) but had a lower rate of postoperative cardiac events (2.5% vs. 4.0%; p = 0.04).ConclusionThe evidence from recent studies, combined with previous ones, further suggests that the dogma of the necessity of mechanical bowel preparation before elective colorectal surgery should be reconsidered.