Pasquale Giordano

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.

Previous sphincter repair does not affect the outcome of repeat repair

AbstractPURPOSE: As many as 60 percent of patients present with recurrent symptoms of fecal incontinence after anterior overlapping anal sphincter repair. The aim of this study was to assess the outcome of repeat overlapping anal sphincter repair. METHODS: All female patients with obstetric sphincter damage who underwent anterior overlapping sphincter repair between November 1988 and June 2000 were reviewed. All patients were preoperatively assessed by anorectal manometry, electromyography, and pudendal nerve terminal motor latency; manometry was repeated during follow-up. Preoperative endoanal ultrasonography was available only after 1990. Clinical outcome was assessed according to the Cleveland Clinic Florida Incontinence Score. RESULTS: One hundred fifty-one patients were available for analysis, 115 without previous surgery and 36 after at least one previous sphincter repair. The median follow-up was 13 (range, 1–64) months and 20 (range, 2–96) months, respectively. The median incontinence score improved from 18 to 5 (P < 0.0001) in patients without previous repair and from 17.5 to 7 (P < 0.0001) in patients after previous repair. In the former group, the outcome was good in 67 (58 percent) patients, adequate in 19 (16.5 percent), and poor in 29 (25.5 percent). In the group with previous sphincter repair, the outcome was good in 18 patients (50 percent), adequate in 4 (11 percent), and poor in 14 (39 percent; P = 0.2646). The mean resting pressure increased from 20 (range, 3–43) mmHg to 24 (range, 10–44) mmHg and from 27 (range, 4–56) mmHg to 32 (range, 16–45) mmHg, respectively. The mean squeeze pressure increased from 60 (range, 23–63) mmHg to 67 (range, 33–114) mmHg and from 54 (range, 25–90) mmHg to 70 (range, 34–95) mmHg, respectively. CONCLUSION: Previous sphincter repair does not affect clinical outcome. Repeat anterior overlapping sphincter repair yields a significant improvement in the continence score and should be considered as the treatment of choice in patients with fecal incontinence who have had previous sphincter repair and residual anterior sphincter damage.

Buschke-Lowenstein tumor successful treatment by surgical excision alone: a case report.

Perianal giant condyloma acuminatum is a rare variant of condyloma acuminata and often represents a therapeutic challenge. We report a case successfully treated with surgical excision alone.

Strategies of follow-up for colorectal cancer: a survey of the American Society of Colon and Rectal Surgeons.

AbstractBackgroundThe postoperative surveillance of patients who have undergone curative treatment for colorectal cancer (CRC) is controversial. The aim of this study was to investigate the follow-up practice of colorectal surgeons in the United States.Methods A postal survey was sent to 1641 active members of the American Society of Colon and Rectal Surgeons practicing in the United States to assess the frequency of follow-up and the methods used in the surveillance of asymptomatic patients following curative surgery for CRC.ResultsOnly 582 (36%) of the questionnaires that were sent were returned fully completed. Of these, 173 surgeons (30%) followed their patients according to guidelines. Ninety-four percent of surgeons during the first year and 81% during the second year saw their patients regularly every 3 or 6 months. The most widely used tests were colonoscopy and carcinoembryonic antigen (CEA) testing. There was wide discrepancy in the frequency of follow-up and techniques employed, with only about 50% of surgeons following recommended practice.ConclusionsSurveillance strategies mainly rely on clinical examination, CEA monitoring and colonoscopy. No clear consensus on surveillance programs for CRC patients exists.

Obliteration of the Rectal Lumen After Stapled Hemorrhoidopexy: Report of a Case

We report an incident of complete stapled closure of the rectal lumen following stapled hemorrhoidopexy. A patient with symptomatic prolapsing hemorrhoids underwent a stapled hemorrhoidopexy as a day-case procedure. After application of the pursestring suture and firing of the dedicated stapler the rectal lumen was found to have been completely obliterated. Endoscopic assessment using a flexible sigmoidoscope confirmed the absence of a rectal lumen. The patient was woken up and a gastrograffin enema performed. Contrast was injected under high pressure into the rectal lumen and a small defect in the mid point of the staple line was revealed. A fine guidewire was passed and endoscopic balloon dilatation achieved. This complication could have had catastrophic consequences and potentially required major surgical intervention. Although unlikely to occur, we believe that surgeons should be aware of this possible problem and a radiologic/endoscopic approach should be considered before more aggressive surgical intervention is undertaken.

The assessment of fecal incontinence in women.

Fecal incontinence is a common problem in women after vaginal delivery. Overt sphincter damage from a third or fourth degree tear occurs in approximately 0.6% to 3% of women undergoing vaginal delivery. Twenty-nine percent to 48% of these patients develop anal incontinence between 3 months and 3 years after primary sphincter repair. Between 6.8% and 35% of primiparal and 12% and 44% of multiparal women have occult sphincter damage recognized on endoanal ultrasonography (EAUS) (Table 1). From one-third to two-thirds of women with such sphincter damage recognized on EAUS have bowel symptoms such as urgency or anal incontinenence. After vaginal delivery pudendal nerve conduction can also be impaired. Prolonged pudendal nerve terminal motor latency (PNTML) is thought to occur in 42% of women who undergo vaginal delivery. Subsequent recovery is noted in 60% of these patients within the first 2 months after delivery. Muscular and neurologic damage may also coexist. Indeed 60% of incontinent women who have sustained an obstetric injury to the external anal sphincter have prolonged PNTML. Both severity and the prevalence of fecal incontinence increase with age, suggesting that other factors may also be involved. A progressive denervation of the anal sphincter muscles may be responsible for the delayed onset of fecal incontinence. But no clear correlation can be demonstrated between the weakness of the external anal sphincter and PNTML in elderly incontinent patients. These findings suggest that in this population a contribution to the weakness of external anal sphincter may be a decrease in the activity of the anterior horn cells in the spinal cord or the reduction in upper motor neurons caused by old age. The reduction in strength of the connective tissue fascia that occurs with the decline of estrogen production at menopause might weaken the pelvic floor and exacerbate any tendency to pudendal neuropathy caused by obstetric factors. This plethora of contributors mandates accurate assessment of anorectal and pelvic floor function in women with fecal incontinence to correctly identify the cause of the incontinence and to plan the most appropriate treatment.

The Italian Society of Colo-Rectal Surgery Annual Report 2010: an educational review

The main purpose of the Italian Society of Colorectal Surgery (SICCR) is to enhance the science and standard of care of patients with colorectal diseases in our Country. The Annual Report (AR) from the Coloproctology Units (UCP) affiliated to the Society was introduced in 1993 in order to monitor their activity and includes four sections covering the most important colo-rectal diseases and their different possibilities of care. From its introduction, it has been improved, being now more articulated and including not only simply the figures of surgical procedures but also alternative treatments, the ratio between observed and operated patients, the percentage of the most common complications (i.e. anastomotic dehiscence). The overall data are analysed and compared with those from the previous years, and results are presented at the annual UCP Club meeting, where co-ordinators of the UCP are requested to attend. This meeting, that is considered very important in the society-life, aims to favour discussion and comparison amongst UCP co-ordinators, to highlight possible differences amongst centres and to address possible issues of wrong practice. The goal is to recall the attention of the coordinators on the standard of the surgical management of their patients. In the same direction, debating at the conclusion of the 2011 UCP meeting, which was held last May in Venice, we thought that a judgment given by some international experts in colo-rectal surgery would have been beneficial. Pasquale Giordano was then asked to comment the Proctology section (condylomata, fissures, haemorrhoids and fistulae), Andrew Zbar commented the Functional Diseases section (megacolon, obstructed defecation, proctalgia, entero-rectocele, rectal prolapse), Steven Wexner the IBD section (ulcerative colitis, Crohn’s disease and also diverticular disease) and Francis Seow-Choen the Cancer section (anal cancer, colon and rectal carcinoma and polyps).