Marco Gallinella Muzi

Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease

BACKGROUND The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure. METHODS A total of 260 patients with sacrococcygeal pilonidal disease were assigned randomly to undergo Limberg flap procedure or tension-free primary closure. RESULTS Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure (P = .0793). Surgical time for primary closure was shorter. Wound infection was more frequent in the primary closure group (P = .0254), which experienced less postoperative pain (P < .0001). No significant difference was found in time off from work (P = .672) and wound dehiscence. Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group (P = .153). CONCLUSIONS Our results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.

Dermoid cyst of the pancreas: presentation and management

BackgroundDermoid cyst of the pancreas is a benign, well-differentiated, extremely rare germ cell neoplasm. Published data indicate that differential diagnosis of cystic lesions of the pancreas is challenging and although ultrasonography, computed tomography and magnetic resonance may be useful, radiological findings are often inconclusive and the diagnosis is intraoperative. We report a case of a dermoid cyst of the tail of the pancreas intraoperatively diagnosed and successfully treated with left pancreatectomy. Further, characteristics, preoperative detection and differential diagnosis of this rare pathology are also discussed.Case presentationThis report documents the findings of a 64-year-old male presenting with a well defined echogenic pancreatic mass on ultrasonography. Computerized Tomography (CT) showed a 5 cm cystic tumor arising from pancreatic tail and Magnetic Resonance Imaging (MRI) suggested a tumor extension to the middle side of the stomach without defined margins. A left pancreatectomy was performed. On surgical specimen, histological evaluation revealed a dermoid cyst of the tail of the pancreas measuring 8.5 × 3.0 cm.ConclusionGiven the benign nature of the dermoid cyst, surgical resection most likely represents the definitive treatment and cure. In addition, resection is indicated in consideration of the difficulty in diagnosing dermoid cyst preoperatively. However, endoscopic ultrasound and fine needle aspiration cytology have recently been shown to be effective, safe, reliable and cost-saving preoperative diagnostic tools. Therefore, until more cases of dermoid cyst are identified to further elucidate its natural history and improve the reliability of the preoperative diagnostic tools, surgical resection should be considered the standard therapy in order to exclude malignancy.

Helicobacter pylori and gastroesophageal reflux disease

BackgroundThe nature of the relationship between Helicobacter pylori and reflux oesophagitis is still not clear. To investigate the correlation between Helicobacter pylori infection and GERD taking into account endoscopic, pH-metric and histopathological data.MethodsBetween January 2001 and January 2003 a prospective study was performed in 146 patients with GERD in order to determine the prevalence of Helicobacter pylori infection at gastric mucosa; further the value of the De Meester score endoscopic, manometric and pH-metric parameters, i.e. reflux episodes, pathological reflux episodes and extent of oesophageal acid exposure, of the patients with and without Helicobacter pylori infection were studied and statistically compared. Finally, univariate analysis of the above mentioned data were performed in order to evaluate the statistical correlation with reflux esophagitis.ResultsThere were no statistically significant differences between the two groups, HP infected and HP negative patients, regarding age, gender and type of symptoms. There was no statistical difference between the two groups regarding severity of symptoms and manometric parameters. The value of the De Meester score and the ph-metric parameters were similar in both groups. On univariate analysis, we observed that hiatal hernia (p = 0,01), LES size (p = 0,05), oesophageal wave length (p = 0,01) and pathological reflux number (p = 0,05) were significantly related to the presence of reflux oesophagitis.ConclusionBased on these findings, it seems that there is no significant evidence for an important role for H. pylori infection in the development of GERD and erosive esophagitis. Nevertheless, current data do not provide sufficient evidence to define the relationship between HP and GERD. Further assessments in prospective large studies are warranted.

Prevalence of Thyroid Cancer in Hyperthyroid Patients Treated by Surgery

A retrospective study has been carried out to evaluate the prevalence of malignant thyroid tumors in 202 patients submitted to surgery for hyperthyroidism. Thyroid cancer was diagnosed in 12 cases (5.9%); the final histologic examination revealed nine papillary carcinomas, one follicular carcinoma, and two Hürthle cell carcinomas. Concurrence of hyperthyroidism and thyroid cancer was more frequent in patients with single toxic adenomas than in those with toxic diffuse or multinodular goiters. In five cases thyroid malignancy was detected in the context of the hyperthyroid lesion (three toxic adenomas and two diffuse goiters). In eight patients the malignant lesion showed a maximum diameter of less than 1 cm, although in five of these cases unfavorable histologic features, such as minimal capsular invasion or multifocality, were present. All patients presenting with thyroid cancer are currently alive and apparently free of residual disease. It is concluded that hyperthyroid patients, particularly those with single toxic adenomas, should be carefully evaluated to exclude the presence of an associated malignancy and to plan the most appropriate therapeutic options.

Long saphenous vein stripping reduces local level of reactive oxygen metabolites in patients with varicose disease of the lower limbs.

Long saphenous vein (LSV) stripping is the most common surgical procedure in patients affected by varicose disease of the lower limbs. Reactive oxygen metabolites (ROM) generation plays a crucial role in chronic venous insufficiency (CVI). The aim of this study was to investigate whether ROM generation is increased in patients affected by varicose disease versus healthy controls and whether LSV stripping has a positive effect on the local production of ROM. The local production of ROM was assessed measuring hydroperoxides in the blood collected from the leg of 30 patients consecutively undergoing LSV stripping and 30 controls. In both the patient group and the control group, the test was repeated 30 days later. We found that ROM levels before surgery are higher in varicose vein patients than in controls (p < .0001) and that ROM are significantly reduced 30 days after LSV stripping (p < .0001). At that time point, no significant differences between patients and controls was found. We also found that sex and age do not affect ROM concentration in patients and controls, either before or after surgery. In conclusion, our data indicate that CVI is characterized by significant oxidative stress and that LSV stripping is able to normalize local production of ROM in patients with varicose disease of the lower limbs. We suggest that measurement of ROM might be useful to test the positive effects of LSV stripping in these patients.

Evaluation of clinical, laboratory and morphologic prognostic factors in colon cancer

BackgroundThe long-term prognosis of patients with colon cancer is dependent on many factors. To investigate the influence of a series of clinical, laboratory and morphological variables on prognosis of colon carcinoma we conducted a retrospective analysis of our data.MethodsNinety-two patients with colon cancer, who underwent surgical resection between January 1999 and December 2001, were analyzed. On survival analysis, demographics, clinical, laboratory and pathomorphological parameters were tested for their potential prognostic value. Furthermore, univariate and multivariate analysis of the above mentioned data were performed considering the depth of tumour invasion into the bowel wall as independent variable.ResultsOn survival analysis we found that depth of tumour invasion (P < 0.001; F-ratio 2.11), type of operation (P < 0.001; F-ratio 3.51) and CT scanning (P < 0.001; F-ratio 5.21) were predictors of survival. Considering the degree of mural invasion as independent variable, on univariate analysis, we observed that mucorrhea, anismus, hematocrit, WBC count, fibrinogen value and CT scanning were significantly related to the degree of mural invasion of the cancer. On the multivariate analysis, fibrinogen value was the most statistically significant variable (P < 0.001) with the highest F-ratio (F-ratio 5.86). Finally, in the present study, the tumour site was significantly related neither to the survival nor to the mural invasion of the tumour.ConclusionThe various clinical, laboratory and patho-morphological parameters showed different prognostic value for colon carcinoma. In the future, preoperative prognostic markers will probably gain relevance in order to make a proper choice between surgery, chemotherapy and radiotherapy. Nevertheless, current data do not provide sufficient evidence for preoperative stratification of high and low risk patients. Further assessments in prospective large studies are warranted.

Aztreonam Biliary Excretion in Bile Duct Ligated Jaundiced Rats

An experimental study was undertaken to assess aztreonam biliary concentrations in bile duct ligated jaundiced rats. The study proved that aztreonam biliary concentrations are sufficient to inhibit Gram-negative bacteria within the first and the second hour after antibiotic administration. The experimental model suggests that clinical conditions such as lithiasis or neoplasms of the biliary tree should not totally inhibit the antibiotic excretion.

Prolapse and hemorrhoids: advances and insights in treatment

To the Editor—We read with great interest the review of randomized, controlled trials comparing stapled hemorrhoidopexy to conventional hemorrhoidectomy by Drs. Tjandra and Chan. In this large review of 25 randomized clinical trials on 1,918 patients, comparing the outcome of stapled hemorrhoidopexy with that of the conventional technique, stapled hemorrhoidopexy is recommended as safe, effective, reproducible procedure with better short-term outcome than conventional technique. In particular, the authors underlined that stapled hemorrhoidopexy is characterized by reduction of postoperative pain and bleeding, faster gastrointestinal and functional recovery, earlier discharge from hospital, and minimal wound care with greater patient satisfaction compared with conventional hemorrhoidectomy. The long-term results of the two procedures are similar. Conversely, Jayaraman et al., in the Cochrane Database System Review about stapled vs. conventional surgery for hemorrhoid treatment, stated that if hemorrhoid recurrence and prolapse are the most important clinical outcomes, the Milligan-Morgan open hemorrhoidectomy remains the standard, given that stapled hemorrhoidopexy is associated with a higher long-term risk of hemorrhoid recurrence and prolapse. Furthermore, as affirmed by Drs. Tjandra and Chan, several trials included in the review are sample limited and not blinded, and the follow-up often is short-term and only in a few trials it is longer than two years. Regarding the effectiveness of hemorrhoidopexy, the stapled mucosectomy is best suited for Grades 2 or 3 hemorrhoids, whereas its efficacy in patients with fourthdegree hemorrhoids is still controversial. Different randomized trials, including patients with fourth-degree hemorrhoids, showed worse results after the stapled technique than after the conventional technique. Moreover, defecation disturbances, such as urgency, were observed after stapled procedure. In fact the consensus position paper about stapled hemorrhoidopexy established that this possibility should be discussed in the informed consent signed by the patient. In a recent French, randomized, multicenter trial of stapler hemorrhoidopexy vs. Milligan-Morgan procedure an overall urgency rate of 12 percent and a overall rate of continence impairment of 10 percent after surgery was reported. In addition, as recently underlined by Ortiz, taking into account the significant variation in the distance of the stapler line above the dentate line, it seems that the technique is not so easily reproducible as previously affirmed. Besides this, in a previous systematic review of 15 trials recruiting 1,077 patients comparing conventional hemorrhoidectomy with stapled hemorrhoidopexy, Nisar and colleagues recommended conventional hemorrhoidectomy as the more effective cure compared with the stapled procedure. Stapled hemorrhoidopexy had a higher recurrence rate (P=0.008) at a minimum follow-up of six months. Furthermore, although the stapled procedure was associated with less postoperative pain, shorter hospitalization, and faster returns to work, studies in a daycase setting did not prove that stapled hemorrhoidopexy was more feasible than conventional hemorrhoidectomy. In contrast, several randomized trials showed that new devices, including ultrasonic scalpel and LigaSureTM (Valleylab, Boulder, Colorado, USA), have been successfully used to perform Milligan-Morgan operation as day-case hemorrhoidectomy, allowing reduction of postoperative pain, decrease of bleeding, fast wound healing, and quick return to work. In a recent randomized trial comparing the LigaSureTM procedure and stapled hemorrhoidopexy, Kraemer and co-workers found no difference in all major aspects analyzed. Postoperative pain scores (P=0.99), patient satisfaction (P=1), and self-assessment of activity (P=0.99) were almost identical in both groups of patients. Besides, a slightly favorable trend for LigaSureTM regarding ease of handling and outcome with fourth-degree piles was detected by the authors. In summary, surgical management of hemorrhoids has undergone extensive reevaluation given the introduction of several instruments including circular stapler,

Diagnostic Accuracy of Radionuclide Venography in the Assessment of Incompetent Perforating Veins of the Legs

The purpose of this study was to evaluate the accuracy of radionuclide venography (RV) (with 99mTc-marked red blood cells) in the identification of incompetent perforating veins (IPVs) of the legs in patients with chronic venous insufficiency. After informed consent, RV, followed by contrast phlebography (CP), of the symptomatic leg was performed in 14 patients (20 legs). The results of RV were compared with those of CP, which was considered the standard technique in detecting IPVs of the leg. The sensitivity of RV was 92.3%; the specificity, 93.7%; the positive predictive value, 96%; the negative predictive value, 88.2%; and the accuracy, 92.9%. The authors conclude that RV has a high diagnostic accuracy in detecting IPVs of the leg.

Evaluation of Renal Tubular Damage in Rats with Biliary Obstruction

Background. It is widely believed that liver disease predisposes towards acute tubular necrosis. The present study evaluates the reliability of urinary enzymes (AGL, AAP) assay in jaundiced rats, its relationship with biochemical data of renal function and pathologic findings of kidney damage.