Marcello Picchio

Stapled and Open Hemorrhoidectomy: Randomized Controlled Trial of Early Results

The aim of the study was to compare the early results in 52 patients randomly allocated to undergo either stapled or open hemorrhoidectomy. Seventy-four patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (37 patients) or open (37 patients) hemorrhoidectomy. Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique. Postoperative pain was assessed by means of a visual analogue scale (V.A.S.). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and a 17.5 (10 to 27)-month median telephone follow-up was obtained in all patients. Operation time for stapled hemorrhoidectomy was shorter (median 25 [range 15 to 49] minutes versus 30 [range 20 to 44] minutes, p = 0.041). Median (range) V.A.S. scores in the stapled group were significantly lower (V.A.S. score after 4 hours: 4 [2 to 6] versus 5 [2 to 8], p = 0.001; V.A.S. score after 24 hours: 3 [1 to 6] versus 5 [3 to 7], p = 0.000; V.A.S. score after first defecation: 5 [3 to 8] versus 7 [3 to 9], p = 0.000). Resumption of pain-free defecation was significantly faster in the stapled group (10 [6 to 14] days vs 12 [9 to 19] days, p = 0.001). At follow-up 4 weeks and 6 months postoperatively the median (range) symptom severity score was similar in both groups (1 [0 to 2] versus 0 [0 to 3], p = 0.150 and 0 [0 to 2] versus 0 [0 to 2], p = 0.731). At long-term follow-up occasional pain was present in 6/37 (16.2) patients in the stapled group and 7/37 (18.9%) in the Milligan-Morgan group (p = 1.000); episodes of bleeding were reported by 8/37 (21.6%) patients in the stapled group and 5/37 (13.5%) patients in the Milligan-Morgan group (p = 0.542). No problems related to continence and defecation were reported in either group. Patients were satisfied with the operation in 33/37 (89.2%) cases in the stapled group and 31/37 (83.8%) cases in the Milligan-Morgan group (p = 0.735). Hemorrhoidectomy with a circular staple device is easy to perform and achieves better results than the Milligan-Morgan technique in terms of postoperative pain and recovery. Comparable results are obtained at long-term follow-up.

Randomised clinical trial: mesalazine and/or probiotics in maintaining remission of symptomatic uncomplicated diverticular disease – a double-blind, randomised, placebo-controlled study

Placebo‐controlled studies in maintaining remission of symptomatic uncomplicated diverticular disease (SUDD) of the colon are lacking.

Stapled vs open hemorrhoidectomy: long-term outcome of a randomized controlled trial

Background and aimsStapled hemorrhoidectomy is a relatively new procedure, and studies on long-term outcomes are few. We present the results of a 5-year follow-up on patients recruited to a randomized controlled trial comparing stapled and Milligan–Morgan hemorrhoidectomy.Patients and methodsWe performed telephone interviews and office visits between May and July 2005 on patients who had taken part in a randomized controlled trial from May 1999 to December 2000.ResultsOccasional pain and bleeding were referred by the patients with no difference between the two groups. The patients were also equally satisfied with both procedures. No recurrent hemorrhoidal prolapse or stenosis was detected at anorectal exploration and rigid sigmoidoscopy.ConclusionBoth stapled and Milligan–Morgan techniques guarantee satisfactory long-term results. Larger studies are needed to assess the durability of stapled hemorrhoidectomy.

Tension-free Laparoscopic and Open Hernia Repair: Randomized Controlled Trial of Early Results

Abstract. The aim of the study was prospectively to compare the early results and outcome in 105 patients randomly allocated to undergo tension-free laparoscopic hernia repair (LHR) with transabdominal preperitoneal technique (53 patients) or open hernia repair (OHR) with mesh apposition (52 patients). The mean (SD) operation time was longer in the LHR group than in the OHR group: 49.6 (5.4) versus 33.9 (6.2) minutes; p < 0.001. One laparoscopic case was converted to open repair to deal with a hemorrhage from an aberrant obturatory artery at the level of Coopers ligament. Groin discomfort or pain was the most common complication after both procedures. The patients requiring none, one, two, or more than two doses of intramuscular diclofenac were, respectively, 40.4%, 40.4%, 15.4%, and 3.8% after LHR and 50.0%, 30.8%, 17.3%, and 1.9% after OHR (p= 0.69; NS). The mean ± SEM (range) postoperative visual analog scale score, ranging from 0 (no pain) to 10 (worst pain imaginable), was 3.1 ± 0.2 (1–7) in the LHR subset and 2.7 ± 0.2 (1–5) in the OHR group (p= 0.14; NS); on the second postoperative day the score was 2.3 ± 0.2 (1–6) and 1.8 ± 0.1 (1–4), respectively (p < 0.03). The time ± SEM (range) of resumption of pain-free normal activities and work was faster in OHR group: 6.1 ± 0.2 (4–8) weeks versus 6.5 ± 0.1 (4–8) weeks; p < 0.03. Our results showed that tension-free open hernia repair is superior to LHR in terms of postoperative pain with no important differences in recovery.

Long-term Outcome of Stapled Hemorrhoidopexy for Grade III and Grade IV Hemorrhoids

PurposeThis study was designed to assess the long-term results of stapled hemorrhoidopexy in 291 patients with Grade III and Grade IV hemorrhoids after a minimum follow-up of five years.MethodsRecords of patients submitted to stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids between January 1999 and December 2002 were retrospectively analyzed. Long-term outcome was evaluated with a standardized questionnaire and an office visit, including anorectal examination and rigid proctoscopy.ResultsA total of 291 patients with Grade III (57.4 percent) and Grade IV (42.6 percent) hemorrhoids were evaluated. Intraoperative (20.3 percent) and postoperative (4.8 percent) bleeding was the most frequent complication. The questionnaire was submitted to all patients at a median follow-up of 73 (range 60–93) months. There were no symptoms related to hemorrhoids in 65.3 percent of patients, moderate symptoms in 25.4 percent of patients, and severe symptoms in 9.3 percent of patients. Fifty-three (18.2 percent) patients had recurrence. Reoperation was necessary in 21 (7.2 percent) patients (4 in Grade III hemorrhoids and 17 in Grade IV hemorrhoids; P < 0.001), with no recurrent symptoms and/or prolapse. Patient satisfaction for operation was 89.7 percent.ConclusionsStapled hemorrhoidopexy is a safe and effective treatment for Grade III and Grade IV hemorrhoids. Recurrence requiring reoperation was higher in Grade IV hemorrhoids than in Grade III hemorrhoids.

Moderate to severe and prolonged left lower-abdominal pain is the best symptom characterizing symptomatic uncomplicated diverticular disease of the colon: a comparison with fecal calprotectin in clinical setting.

Background: Left lower-abdominal pain is considered the best symptom to differentiate between symptomatic uncomplicated diverticular disease (SUDD) and irritable bowel syndrome (IBS). However, this statement has not been validated yet. Goals: The aim of this study was to assess whether prolonged left lower-quadrant pain is the best symptom characterizing SUDD and be able to differentiate SUDD from IBS-like symptoms in diverticulosis, and to compare the location of abdominal pain with fecal calprotectin (FC) expression. Study: Seventy-two patients suffering from abdominal pain and having diverticula at colonoscopy were enrolled. Patients were classified according to SUDD definition (abdominal pain for at least 24 consecutive hours in left lower abdomen) (42 patients) and IBS-like symptoms fulfilling Rome III criteria (30 patients). Abdominal pain was assessed using a 10-point visual scale, assigning numerical values from 0 (absence of pain) to 10 (severe pain). FC expression was assessed by a rapid test in all patients enrolled. Results: FC test was positive in 27 (64.3%) patients in the SUDD group and in no patient in the IBS-like group (P<0.0001). In patients with SUDD, there was a significant correlation between the severity of the abdominal pain and the FC score (P=0.0015). Extension of diverticulosis correlated with FC score (P=0.022) and the severity of diverticulosis (P=0.005). Conclusions: Severe and prolonged left lower-abdominal pain seems to be the best symptom characterizing SUDD, and it can differentiate these patients from those harboring diverticula but suffering from IBS-like according to Rome III criteria.

Musosal tumour necrosis factor α in diverticular disease of the colon is overexpressed with disease severity.

Aim  Inflammation occurs in diverticular disease (DD), but there is little information on inflammatory cytokines such as tumour necrosis factor α (TNF‐α). The aim of this study was to assess TNF‐α expression in DD and to see whether it is related to the severity of the disease.

Interactions between Innate Immunity, Microbiota, and Probiotics.

The term “microbiota” means genetic inheritance associated with microbiota, which is about 100 times larger than the guest. The tolerance of the resident bacterial flora is an important key element of immune cell function. A key role in the interaction between the host and the microbiota is played by Paneth cell, which is able to synthesize and secrete proteins and antimicrobial peptides, such as α/β defensins, cathelicidin, 14 β-glycosidases, C-type lectins, and ribonuclease, in response to various stimuli. Recent studies found probiotics able to preserve intestinal homeostasis by downmodulating the immune response and inducing the development of T regulatory cells. Specific probiotic strain, as well as probiotic-driven metabolic products called “postbiotics,” has been recently recognized and it is able to influence innate immunity. New therapeutic approaches based on probiotics are now available, and further treatments based on postbiotics will come in the future.

Development and Validation of an Endoscopic Classification of Diverticular Disease of the Colon: The DICA Classification

Background: A validated endoscopic classification of diverticular disease (DD) of the colon is lacking at present. Our aim was to develop a simple endoscopic score of DD: the Diverticular Inflammation and Complication Assessment (DICA) score. Methods: The DICA score for DD resulted in the sum of the scores for the extension of diverticulosis, the number of diverticula per region, the presence and type of inflammation, and the presence and type of complications: DICA 1 (≤3), DICA 2 (4-7) and DICA 3 (>7). A comparison with abdominal pain and inflammatory marker expression was also performed. A total of 50 videos of DD patients were reassessed in order to investigate the predictive role of DICA on the outcome of the disease. Results: Overall agreement in using DICA was 0.847 (95% confidence interval, CI, 0.812-0.893): 0.878 (95% CI 0.832-0.895) for DICA 1, 0.765 (95% CI 0.735-0.786) for DICA 2 and 0.891 (95% CI 0.845-0.7923) for DICA 3. Intra-observer agreement (kappa) was 0.91 (95% CI 0.886-0.947). A significant correlation was found between the DICA score and C-reactive protein values (p = 0.0001), as well as between the median pain score and the DICA score (p = 0.0001). With respect to the 50 patients retrospectively reassessed, occurrence/recurrence of disease complications was recorded in 29 patients (58%): 10 (34.5%) were classified as DICA 1 and 19 (65.5%) as DICA 2 (p = 0.036). Conclusions: The DICA score is a simple, reproducible, validated and easy-to-use endoscopic scoring system for DD of the colon.

Long-term outcome of local excision after preoperative chemoradiation for ypT0 rectal cancer.

BACKGROUND:Local excision, as an alternative to radical resection for patients with pathological complete response (ypT0) after preoperative chemoradiation, is under investigation. OBJECTIVE:The aim of the present study was to evaluate the long-term clinical outcome of a selected group of patients with ypT0 rectal cancer who underwent local excision with transanal endoscopic microsurgery as a definitive treatment. PATIENTS:Between 1993 and 2013, 43 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a transanal endoscopic microsurgery procedure after a regimen of chemoradiation. In all patients, rectal wall penetration was preoperatively assessed by endorectal ultrasound and/or magnetic resonance. Chemoradiation and transanal endoscopic microsurgery were indicated in patients refusing radical procedures or patients unfit for major abdominal procedures. MAIN OUTCOME MEASURES:Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed at a median follow-up of 81 months. The potential prognostic factors for recurrence, screened in univariate analysis, were analyzed by multivariate analysis by using the Cox regression model. RESULTS:Thirteen patients (30.2%), without residual tumor in the surgical specimen (ypT0), were treated with transanal endoscopic microsurgery only. In this ypT0 group, 2 patients (15.4%) had postoperative complications: 1 bleeding and 1 suture dehiscence. Postoperative mortality was nil. No local and distal recurrences were observed, and no tumor-related mortality occurred. In 30 patients (69.8%), partial tumor chemoradiation response or the absence of tumor chemoradiation response was observed. In this group, recurrence occurred in 17 patients (56.7%). LIMITATIONS:The study was limited by its retrospective nature, different protocols of chemoradiation and preoperative staging over time, and the small sample size. CONCLUSIONS:Local excision with transanal endoscopic microsurgery can be considered a definitive therapeutic option in patients with rectal cancer treated with preoperative chemoradiation, when no residual tumor is found in the specimen. In this selected group, local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, transanal endoscopic microsurgery should be considered as a large excisional biopsy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A157).