Julio Rafael Mariano da Rocha

Initial experience with stapled hemorrhoidopexy for treatment of hemorrhoids

BACKGROUND Introduction of stapled hemorrhoidopexy by Longo in 1998 represented a radical change in the treatment of hemorrhoids. By avoiding multiple excisions and suture lines in the perianal region, stapled hemorrhoidopexy is intended to offer less postoperative pain than with conventional techniques. OBJECTIVE To report and analyze the intra and postoperative results gained during initial experience with stapled hemorrhoidopexy. METHODS One hundred and fifty five patients (67 males) with average age of 39.5 years (21-67 years) underwent stapled hemorrhoidopexy between June 2000 and December 2003 with symptomatic third-degree (n = 74) and fourth-degree (n = 81) hemorrhoids. Mean follow-up period was 20 months (14-60 months). RESULTS Preoperative symptoms were prolapse (96.7%) and anal bleeding (96.1%). Overall mean operative time was 23 minutes (16-48 minutes). We observed one case of stapler failure and one case of failure to introduce the stapler occurred in a patient with previous anal surgery. Additional sutures for hemostasis were required in 103 patients (66.5%). Resection of skin tags was performed in 45 cases (29%). Postoperatively scheduled analgesia with oral dipyrone and celecoxib was enough for pain control in 131 patients (84.5%). Rescue analgesia was necessary in 24 cases (15.5%). Five patients needed opiates for pain control. Hospital discharge took place on the first postoperative day in 140 patients (90.3%). First defecation without pain was reported by 118 patients (76.1%). Postoperative complications were anal bleeding (10.3%), severe pain (3.2%), urinary retention (3.9%), fever without any signs of perianal infection (1.9%), incontinence for flatus (1.9%), hemorrhoidal thrombosis (1.3%). Two patients presented symptoms of recurrent hemorrhoidal disease and were successfully treated by conventional hemorrhoidectomy. They were no cases of anal stenosis, permanent incontinence, chronic pain or deaths in this series. CONCLUSIONS Hemorrhoidopexy can be considered a feasible and safe alternative technique to conventional hemorroidectomy for select patients.

Alternative technique of laparoscopic hepaticojejunostomy for advanced pancreatic head cancer.

Only 20% of patients with pancreatic cancer can undergo curative resection. Therefore, palliative treatment of pancreatic cancer assumes the utmost clinical importance. The aim of the palliative treatment of pancreatic head carcinoma is to relieve the jaundice and/or duodenal obstruction. Endoscopic or transparietal decompression of the obstructed bile duct can be accomplished in most cases, but the durability of these techniques is not as great as that of a surgically created bypass. On the other hand, hepaticojejunostomy carries higher morbidity and mortality rates than the former nonsurgical methods. In order to promote long lasting palliation with low morbidity and mortality rates, minimally invasive techniques of biliary and gastric bypass have been described. However, laparoscopic Roux-en-Y hepaticojejunostomy seems to be a complex surgical procedure. With an aim to simplify the construction of a laparoscopic hepaticojejunostomy, the authors suggest an alternative technique.

Tratamento laparoscópico de coledocolitíase

With the advances of videolaparoscopic surgery, this approach had become the treatment of choice for cholelithiasis. However, about 5% to 10% may present common bile duct lithiasis. Most surgeons have still difficulties to deal with this situation and do prefer resolve with open surgery or with further endoscopic approach. We present a case of a 60-year-old man, with 18 months history of right upper quadrant pain, weight loss and jaundice. He was referred with diagnostic of pancreatic cancer. Laboratory investigation showed increased bilirubin (10 mg/dL), alkaline phosphatase and GGT. Abdominal ultrasound showed atrophic gallbladder with dilated intra and extrahepatic biliary tree. Computerized tomography scan disclosed enlarged biliary tree with 3 cm stone in the distal common bile duct. The patient underwent a laparoscopic cholecystectomy followed by choledochotomy and retrieval of the large stone. A latero-lateral choledochoduodenum anastomosis was then performed to decompress the biliary tree. The patient had an uneventful recovery being discharged at the 6th postoperative day. Laparoscopic management of choledocholithiasis is feasible in many patients, specially those with dilated biliary tree. The retrieval of stones may be followed by biliary drainage with T-tube. In some elderly patients with chronically dilated common bile duct, as in the present case, a choledochoduodenal anastomosis is the procedure of choice.

Primary malignant melanoma of the esophagus: a rare and aggressive disease

Primary malignant melanoma of the esophagus is an uncommon tumor, with approximately 300 cases having been reported thus far. The purpose of this study was to describe a case of a 60 year-old man with a 10 month history of progressive dysphagia and thoracic pain, the investigations of which led to a diagnosis of primary malignant melanoma of the esophagus. The patient underwent a transhiatal esophagectomy with subcarinal lymphadenectomy, and isoperistaltic gastric tube replacement of the esophagus. Nine months after surgery, he developed ischemic colitis, and metastasis in the mesentery was diagnosed. His disease progressed and he died one year after the esophagectomy. A review of the literature was performed.

Heller-Pinotti, a modified partial fundoplication associated with myotomy to treat achalasia: technical and final results from 445 patients

Aim: The need for an antireflux procedure after myotomy is no longer as controversial as it used to be. However, the choice of the best fundoplication after myotomy is still controversial. The authors present the results of laparoscopic myotomies associated with postero-latero-anterior fundoplications (Heller-Pinotti). Methods: Medical records and endoscopic findings were reviewed for achalasia patients that had submitted to the procedure following 5 years of followup. Results: In total, 445 patients were enrolled: 39 (8.7%) presented erosive esophagitis, the Los Angeles classification being A-21, B-12, C-2 and D-4 (2 with peptic substenosis and 2 Barret); 41 (9.2%) patients had dysphagia, 4 needed reinterventions; 49 (11%) presented a migration of the fundoplication wrap to the thorax due to hiatal hernia, this was correlated with a higher risk of present erosive esophagitis (P = 0.047) and dysphagia (P < 0.001). Conclusion: Laparoscopy myotomy postero-latero-anterior fundoplication (Heller-Pinotti) produces a good long-term outcome for dealing with dysphagia and in terms of reflux prevention.

Barrett’s Esophagus and Carcinoma in the Esophageal Stump After Esophagectomy for Achalasia

We appreciate the interest and comments of Dr. D’Journo and colleagues regarding our article on Barrett’s esophagus and carcinoma in the esophageal stump after esophagectomy for achalasia patients. We have the following comments. Esophagitis, Barrett’s esophagus, dysplasia, and carcinoma in the esophageal stump comprise an intriguing cascade of progression of epithelial damage due to the duodenogastric reflux. Moreover, achalasia patients are at high risk to develop esophageal squamous cell carcinoma. Therefore, our group has followed achalasia patients up very closely, in order to diagnose early or superficial lesions in the esophageal stump mucosa that are amenable to be promptly resected. The appearance of the three cases of squamous cell carcinoma is quite possibly related to long-standing chronic inflammation, mainly if we consider that these three cases have been submitted to several annual endoscopic dilations, during at least 10 years, in order to treat severe anastomotic stenosis, due to esophagogastric (EG) anastomotic fistula. We have shown early events of molecular alterations in the esophageal squamous cell mucosa even before the appearance of the tumors, related to the local inflammation. Two cases that developed in situ adenocarcinoma had shown the following progression: erosive esophagitis ? columnar (pyloric) metaplasia ? intestinal metaplasia ? high-grade dysplasia (13 and 19 years after the operation) ? in situ adenocarcinoma (1 and 3 years after the initial dysplasia identification). They were both treated successfully by endoscopic mucosal resection. As reported in our article, H2 blockers and, more recently, proton pump inhibitors were administered in all patients in order to prevent peptic ulcer formation, at the esophageal remnant or transposed gastric tube. Nevertheless, the use of such medications did not avoid the occurrence of Barrett’s esophagus; however, there was a tendency to delay the appearance and the size of the columnar epithelium. There are no specific operations directed to the suppression of reflux events after gastric interposition. In our opinion, theoretically, a duodenal diversion associated to the usual cervical gastric pull-up could solve this problem, but this is a troublesome procedure, considering the special care required to avoid vascular lesions to the right gastroepiploic vessels (main vascular blood supply to the transposed stomach). We have always performed cervical esophagogastric anastomosis after esophagectomy and gastric pull-up for benign disease (Pinotti’s technique, 1977), in order to decrease gastroesophageal reflux and to avoid occurrence of intrathoracic fistula (main cause of mortality in intrathoracic esophagogastric anastomosis after esophagectomy and gastric pull-up). Esophageal resection is a valid surgical alternative in selected patients with end-stage achalasia. Long-term follow-up has shown to be associated with resolution of dysphagia, reestablishment of normal nutritional status, and early return to labor activities. However, reflux esophagitis and new columnar lined metaplasia are significant complications of esophagectomy with gastric interposition, and we routinely perform surveillance endoscopic examination every year or two years in these patients.