R. Greenberg

Management of Breast Fibroadenomas

OBJECTIVE: To identify from the literature and clinical experience a rational approach to management of fibroadenomas of the breast.METHOD: Recent literature on detection, diagnosis, and natural history of fibroadenomas was reviewed. Experience with over 4,000 women evaluated in the breast clinic at the Tel-Aviv Medical Center contributed to the management strategies suggested by review of the literature.RESULTS: Fibroadenomas of the breast are common, accounting for 50% of all breast biopsies performed. Physical examination, sonography, and fine needle aspiration are effective in distinguishing fibroadenomas from breast cancer. Transformation from fibroadenoma to cancer is rare; regression or resolution is frequent, supporting conservative approaches to follow-up and management.CONCLUSION: Age-based algorithms that allow for conservative management and that limit excision to patients whose fibroadenomas fail to regress are presented.

First 100 Cases With Doppler-Guided Hemorrhoidal Artery Ligation

PurposeThis study was designed to examine the benefits of a Doppler-guided hemorrhoidal artery ligation technique in terms of surgical outcome, functional recovery, and postoperative pain.MethodsUsing local, regional, or general anesthesia, 100 patients with symptomatic Grades II or III hemorrhoids underwent sonographic identification and suture ligation of six to eight terminal branches of the superior rectal artery above the dentate line. Visual Analog Scales were used for postoperative pain scoring. Surgical and functional outcomes were assessed at 6 weeks and 3, 6, and 12 months after surgery.ResultsThere were 42 (42 percent) males and 58 (58 percent) females (mean age, 42 years; median duration of symptoms, 6.3 years). The mean operative time was 19 minutes. Local anal block combined with intravenous sedation (n = 93) or general or spinal (n = 7) anesthesia was used. Only five were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative course. The mean pain score decreased from 2.1 at two hours postoperative to 1.3 on the first postoperative day. All patients had a complete functional recovery by the third postoperative day. Ninety-four patients remained asymptomatic after a mean follow-up of six months: four patients required additional surgical excision, and two required rubber band ligations for persistent bleeding. On follow-up, there was no report of incontinence to gas or feces, fecal impaction, or persistent pain.ConclusionsOur experience indicates that Doppler-guided hemorrhoidal artery ligation is safe and effective and can be performed as an outpatient procedure with local or regional anesthesia and with minimal postoperative pain and early recovery.

Five-year follow-up of Doppler-guided hemorrhoidal artery ligation

BackgroundDoppler-guided hemorrhoidal artery ligation (DGHAL) was described as lower risk and a less painful alternative to hemorrhoidectomy. We report our experience and 5-year follow-up with this procedure.MethodsBetween May 2003 and December 2004, 100 patients with symptomatic Grade II or III hemorrhoids underwent ultrasound identification and ligation of 6–8 terminal branches of the superior rectal artery above the dentate line by a single surgeon using local, regional, or general anesthesia. There were 42 men and 58 women (mean age 42xa0years, median duration of symptoms 6/3xa0years). A 10-point visual analog scale was used for postoperative pain scoring. Surgical and functional outcome was assessed at 6xa0weeks and 3 and 12xa0months after surgery, with long-term follow-up by a telephone questionnaire at 5xa0years after the procedure.ResultsThe mean operative time was 19xa0min. Local anal block combined with intravenous sedation (nxa0=xa093) or general or spinal (nxa0=xa07) anesthesia was used. Only 5 patients were hospitalized overnight. There was no urinary retention, bleeding, or mortality in the immediate postoperative period. The mean pain score decreased from 2.1 at 2xa0h postoperatively to 1.3 on the first postoperative day. All patients had complete functional recovery by the third postoperative day. Ninety-six patients completed 12xa0months of follow-up. Eighty-five of these patients (89%) remained asymptomatic at 12xa0months, though this number dropped to 67/92 (73%) at 5xa0years.ConclusionsLong-term follow-up confirms the effectiveness of the DGHAL procedure for treatment for Grade II hemorrhoids. The DGHAL procedure alone seems less effective for Grade III hemorrhoids.

Outcome of stapled hemorrhoidopexy versus doppler-guided hemorrhoidal artery ligation for grade III hemorrhoids

PurposeTo evaluate the long-term results, early and late complication rates, and overall satisfaction of patients with grade III hemorrhoids treated by stapled hemorrhoidopexy (SH) or Doppler-guided hemorrhoidal artery ligation (DGHAL).MethodsOperative and follow-up patients’ data were prospectively collected for patients undergoing either SH or DGHAL by a single surgeon during a 2-year period. A retrospective comparison between patients’ outcome operated by one of the two methods was made based on this data. Clinical data on postoperative pain, analgesic requirements, time to first bowel movement and functional recovery were collected at five postoperative follow-up visits (1 and 6xa0weeks, 6, 12, and 18xa0months). Data on patient satisfaction, recurrence of hemorrhoidal symptoms and further treatments were obtained by a standardized questionnaire that was conducted during the last visit 18xa0months postoperatively.ResultsA total of 63 patients underwent SH (aged 52xa0±xa03.2xa0years) and 51 patients underwent DGHAL (aged 50xa0±xa07.3xa0years). DGHAL patients experienced less postoperative pain as scored by pain during bowel movement (2.1xa0±xa01.4 vs. 5.5xa0±xa01.9 for SH), and required fewer analgesics postoperatively. Hospital stay, time to first bowel movement, and complete functional recovery were also significantly shorter for the DGHAL patients. Nine DGHAL patients (18%) suffered from persistent bleeding or prolapses and required additional treatment compared with 2 (3%) patients in the SH group. SH patients reported greater satisfaction compared with DGHAL patients at 1xa0year postoperatively.ConclusionBoth SH and DGHAL are safe procedures and have similar effectiveness for treating grade III hemorrhoids. DGHAL is less painful and provides earlier functional recovery, but is associated with higher recurrence rates and lower satisfaction rates compared with SH.

Doppler-guided haemorrhoidal artery ligation in patients with Crohn's disease.

Aim:u2002 The outcome of Doppler‐guided haemorrhoidal artery ligation (DGHAL) was assessed in patients with Crohn’s disease (CD) suffering from grade III haemorrhoids.

C-reactive protein as a marker of complicated diverticulitis in patients on anti-inflammatory medications

BackgroundDiverticulitis is a common indication for surgical emergency room admission, often leading to abdominal computed tomography (CT) scanning for both diagnosis and staging. C-reactive protein (CRP) has been identified as a useful biomarker of inflammation. Aspirin and corticosteroids are known to down-regulate CRP production. In this study, we evaluated the usefulness of CRP as a biomarker for complicated diverticulitis and specifically in patients on anti-inflammatory medications: aspirin and corticosteroids.MethodsWe analyzed the medical records of patients diagnosed at one medical center during a two-year period, with left-sided diverticulitis, according to clinical data and CT scan. Disease severity was assessed by the Hinchey score using the radiological findings detected by CT.ResultsA total of 295 patients were included in the study. Two hundred and forty-three (82xa0%) were classified with uncomplicated (Hinchey 1a) and 52 (18xa0%) with complicated disease (Hincheyxa0>xa01a). Mean CRP levels were 133.5 and 63.5xa0mg/ml for those with complicated and uncomplicated disease, respectively (pxa0<xa00.001), and 139 and 60xa0mg/ml, respectively (pxa0<xa00.001) in the subgroup of patients taking aspirin (nxa0=xa061). For 14 patients on corticosteroid treatment, the difference in mean CRP levels for complicated and uncomplicated disease was not statistically significant. CRPxa0>xa090xa0mg/ml had 88xa0% sensitivity and 75xa0% specificity for complicated disease.ConclusionsThe CRP level distinguished between complicated and uncomplicated disease among left-sided diverticulitis patients including those taking aspirin, but not among those on corticosteroid treatment.

Perioperative blood transfusion in cancer patients undergoing laparoscopic colorectal resection: risk factors and impact on survival

BackgroundPerioperative blood transfusion has been associated with a poor prognosis in patients undergoing surgery for colorectal cancer. The aim of this study was to evaluate risk factors for blood transfusion and its impact on long-term outcome exclusively in patients undergoing laparoscopic surgery for curable colorectal cancer.MethodsData were retrieved from a prospectively collected database of patients who underwent laparoscopic surgery for curable colorectal cancer over a 6-year period. Long-term data were collected from our outpatient clinic and personal contact when necessary.ResultsTwo hundred and one patients underwent laparoscopic surgery for curable colorectal cancer (stage I–III). Sixty-eight (33.8xa0%) received blood transfusions during or after surgery. These patients were typically older, had lower preoperative hemoglobin levels, had a more advanced cancer, had a higher Charlson score, had a higher rate of complications and had a higher conversion rate. Kaplan–Meier overall survival analysis was significantly worse in patients who received blood transfusions (Pxa0=xa00.004). Decreased disease-free survival was also observed in transfused patients; however, this did not reach statistical significance (Pxa0=xa00.21). A multivariate analysis revealed that transfusion was not an independent risk factor for decreased overall and disease-free survival. The Charlson score was the only independent risk factor for overall survival (ORxa0=xa02.1, Pxa0=xa00.002). Independent factors affecting disease-free survival were stage of disease, Charlson score and, to a lesser degree, age and body mass index.ConclusionsPerioperative blood transfusion is associated with decreased long-term survival in patients undergoing laparoscopic resection for colorectal cancer. However, this association apparently reflects the poorer medical condition of patients requiring surgery and not a causative relationship.

Detection of hepatocyte growth factor/scatter factor receptor (c-Met) in axillary drainage after operations for breast cancer using reverse transcriptase–polymerase chain reaction

BackgroundThe diverse biological effects of hepatocyte growth factor/scatter factor (HGF/SF) are mediated by c-Met, which is preferentially expressed on epithelial cells. Met signaling has a role in normal cellular activities, and may be associated with the development and progression of malignant processes. In this study we examined whether Met can be detected in the axillary drainage from patients who underwent conservative operations for breast cancer, and its prognostic significance.MethodsThirty-one consecutive patients with invasive ductal carcinoma of the breast suitable for breast-conserving treatment were studied. The output of the drain that had been placed in the axilla during the operation was collected, and the presence of Met and β-actin were assessed by reverse transcriptase–polymerase chain reaction (RT–PCR) assays. The data were compared with the pathological features of the tumor and the axillary lymph nodes, and with the estrogen receptor and progesterone receptor status.ResultsRT–PCR of the axillary lymphatic drainage was positive for Met in 23 (74.2%) of the patients. Positive assays were correlated with increasing tumor size and grade, with capillary and lymphatic invasion, and with lymph node metastasis (P < 0.02, for all comparisons). All 12 patients with axillary lymph node metastases had positive assays for Met, compared with 57.9% of patients without lymph node metastases. All five patients with tumor involvement in the margins of the resection had positive assays for Met in their lymphatic fluid, compared with 18 of 26 positive assays (69.2%) for patients without involved margins (P < 0.04). Finally, Met showed negative correlations with positivity for estrogen receptor and progesterone receptor (P < 0.02).ConclusionMet can be detected in the axillary fluids of patients with breast cancer and its expression in the axillary drainage may have potential as a prognostic factor. This finding might be relevant to therapeutic considerations, because a positive assay for Met in histologically node-negative patients might point to the need to search for node microinvasion or involvement of the excision margins with tumor.

Outcome of repeated stapler haemorrhoidopexy for recurrent prolapsing haemorrhoids.

Aimu2002 Stapled haemorrhoidopexy (SH) is associated with minor postoperative pain and high overall satisfaction rates. Some patients will have persistent or recurrent symptoms requiring re‐intervention.

Is Doppler ultrasonography essential for hemorrhoidal artery ligation

BackgroundDoppler ultrasonography enables accurate identification of the terminal branches of the superior rectal artery prior to hemorrhoidal artery ligation (HAL). However, since the positions of these branches have been found to be relatively constant, the question arises as to the necessity of ultrasonography for their identification. The aim of the current study was to examine the positions of all arteries identified and ligated during the HAL procedure.MethodsWe recorded the position of all arteries located and ligated in 135 consecutive patients who underwent the HAL procedure during the years 2003 to 2006.ResultsIn all patients, 6–8 terminal arterial branches were located above the dentate line. In 102 (76xa0%) patients, terminal branches were located in all 6 of the odd-numbered clock positions around the anus (1, 3, 5, 7, 9, and 11 o’clock in the lithotomy position). If we had ligated arteries only at these odd-numbered clock positions, without using Doppler ultrasonography, we would have located all the arteries in 96 (71xa0%) of our patients.ConclusionsThe number and location of arterial branches of the superior rectal artery are relatively constant. Nevertheless, if, Doppler ultrasonography had not been performed and, ligation in the HAL procedure had been at the odd-numbered clock positions only, then at least one artery would have been missed in 29xa0% of our patients.