Marco Chiarelli

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.

An Incidental Pulmonary Meningioma Revealing an Intracranial Meningioma: Primary or Secondary Lesion?

A 68-year-old man underwent a resection of the right middle lobe for a solitary lesion detected at computed tomography. The histologic result was suggestive for a pulmonary meningioma. Although the result of a preoperative brain computed tomography scan was negative, magnetic resonance imaging showed a skull-base meningioma. On the basis of the absence of symptoms, we decided to observe the intracranial meningioma. At 3 years of follow-up, the patient was free of recurrence and the cerebral lesion was stable. Primary pulmonary meningioma and benign meningioma metastasis share identical microscopic findings, and only a central nervous system radiologic study allows their distinction. The pulmonary lesion in our patient was classified as a meningioma metastasis.

The Wandering Spleen

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Chylothorax after mediastinal ganglioneuroma resection treated with fibrin sealant patch: a case report

Chylothorax is a severe condition resulting from the accumulation of chyle into the pleural space. We report the treatment of postoperative chylothorax after resection of mediastinal ganglioneuroma in a 17-year-old boy. Since conservative measures were not effective, we performed direct ligation of lymphatic vessels and pleurodesis. At subsequent surgical re-exploration for persisting chylothorax, accurate inspection of pleural cavity revealed residual chyle leakage. Fibrin sealant patches (TachoSil®) were placed over the source of leak with complete resolution of chylous effusion. To our knowledge, this is the first report of postoperative chylothorax successfully treated by the use of a fibrin sealant patch.

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

BACKGROUND The 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%. METHODS Over 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%. RESULTS We 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. CONCLUSIONS Mortality 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.

Advantages of wound retractor device versus rigid trocar at camera port in video-assisted thoracic surgery—a single institution experience

Background rigid trocars are widely adopted in video-assisted thoracic surgery (VATS), despite some disadvantages: (I) cannula strong pressure on intercostal nerve stimulating postoperative pain; (II) limited movement of thoracoscopic devices on their fulcrum when extreme acute angles with the chest wall are needed. Wound retractor (WR) device, designed for laparoscopic surgery, it is also used in VATS, but to protect mini-thoracotomy. We compared the use of extra-small WR versus rigid trocar at camera port that is the most painful thoracostomy. The aim was to determine if WR is associated with less postoperative pain and better scope maneuverability. Methods This is a single institution prospective study recorded and approved by ethics committee at our hospital. From October 2016 to June 2017, we enrolled 40 patients (statistical power 88%), randomized into two different groups. Group A (20 patients) underwent VATS lung resection using WR at camera port, group B (20 patients) using rigid trocar. Intra-operative data collected were maximum acute angle obtained between the camera and chest wall and chest wall thickness. Pain was measured by numerical analog scales (NAS) at 6, 12, 24, 48 and 72 hours after surgery. We also measured total morphine consumption at 72 h administered by patient controlled analgesia (PCA) system. Results No statistical significance was found in the demographic traits of the two groups (P=1). Statistically significant differences were found in favor of group A for both pain control, morphine consumption (P<0.001) and camera maneuverability (described as maximum acute angle obtained/chest wall thickness) (P<0.001). Conclusions patients who had WR showed less postoperative pain. Moreover, WR presented other advantages: camera protection by small bleeding from chest wall, adaptability with every chest wall thickness, absence of skin injury around the port. We suggest its use instead of rigid trocar.

Wirsung atraumatic rupture in patient with pancreatic pseudocysts: a case presentation

BackgroundPancreatic duct disruption is a challenging condition leading to pancreatic juice leakage and consequently to pancreatic fluid collections. The manifestations of pancreatic main duct leak include pseudocysts, walled-off necrosis, pancreatic fistulas, ascites, pleural and pericardial effusions. Pseudocyst formation is the most frequent outcome of a pancreatic duct leak.Case presentationWe describe a case of a 64-year old man with large multiple pancreatic cysts discovered for progressive jaundice and significant weight loss in the absence of a previous episode of acute pancreatitis. Computed tomography scan showed lesion with thick enhancing walls. The main cyst dislocated the stomach and the duodenum inducing intra and extrahepatic bile ducts enlargement. Magnetic resonance cholangiopancreatography revealed a communication between the main pancreatic duct and the cystic lesions due to Wirsung duct rupture. Endoscopic ultrasound guided fine needle aspiration cytology did not show neoplastic cells and cyst fluid analysis revealed high amylase concentration. Preoperative exams were suggestive but not conclusive for a benign lesion. Laparotomy was necessary to confirm the presence of large communicating pseudocysts whose drainage was performed by cystogastrostomy. Histology confirmed the inflammatory nature of the cyst wall. Subsequently, the patient had progressive jaundice resolution.ConclusionPancreatic cystic masses include several pathological entities, ranging from benign to malignant lesions. Rarely pseudocysts present as complex cystic pancreatic lesions with biliary compression in absence of history of acute pancreatitis. We describe the rare case of multiple pancreatic pseudocysts due to Wirsung duct rupture in absence of previous trauma or acute pancreatitis. Magnetic resonance showed the presence of communication with the main pancreatic duct and endoscopic ultrasound fine needle aspiration suggested the benign nature of the lesion.