S. Avital

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.

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.

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.

A surgical solution to regain bowel continuity following an extended left colectomy—reviving and extending the indication for a “Flip-Flop” procedure

Background and aimsExtended left hemicolectomy might be necessary for several indications. Once the resection is completed, it would be difficult or impossible to anastomose the transverse colon to the rectum due to the difficulty in mobilizing the transverse colon to reach for a tension-free rectal anastomosis. The aim of this report is to present the “Flip-Flop” technique to overcome this challenging situation. The procedure is based on a surgical technique published in the early 1960s to avoid permanent stoma after proctectomy and consists of changing the location of the right colon to reach the rectum.MethodsClinical parameters, surgical aspects, and postoperative outcome of patients that underwent the flip-flop procedure following an extended left colectomy in our medical service was reviewed.ResultsThree patients underwent a flip-flop procedure after an extended left colectomy performed for various reasons. The surgical technique is detailed in a step by step manner. Patients had uneventful postoperative recovery with an adequate functional outcome.ConclusionsWe believe that this approach should be revived and be considered also in cases when the full length of the rectum is preserved to avoid ileo-rectal anastomosis or a high-tension colocolonic anastomosis. Popularization of this surgical solution among surgeons is highly important.

Comparison between laparoscopic and open Hartmann’s reversal: results of a decade-long multicenter retrospective study

BackgroundHartmann’s reversal is a challenging surgical procedure with significant postoperative morbidity rates. Various surgical methods have been suggested to lower the risk of postoperative complications. In this study, we aimed to compare the postoperative results between open and laparoscopic techniques for Hartmann’s reversal.MethodsA retrospective study of all patients who underwent Hartmann’s reversal in five centers in central Israel between January 2004 and June 2015 was conducted. Medical charts were reviewed, analyzing preoperative and operative parameters and short-term postoperative outcomes.Results260 patients were included in the study. 76 patients were operated laparoscopically with a conversion rate of 26.3% (20 patients). No differences were found between patients operated laparoscopically and those operated in an open technique regarding gender (pu2009=u20090.785), age (61.34 vs. 62.64, pu2009=u20090.521), body mass index (26.6 vs. 26.2, pu2009=u20090.948), Charlson index score (1.79 vs. 1.95, pu2009=u20090.667), and cause for Hartmann’s procedure (neoplastic vs. non-neoplastic, pu2009=u20090.644). No differences were seen in average time from the Hartmann’s procedure to reversal (204.89 vs. 213.60xa0days, pu2009=u20090.688) and in overall complication rate (46.4 vs. 46.5%, pu2009=u20091). The Clavien–Dindo score for distinguishing between minor (0–2 score, pu2009=u20091) and major complications (3–5 score, pu2009=u20090.675) failed to demonstrate an advantage to laparoscopy, as well as to average length of stay (10.91xa0days in the laparoscopic group vs. 11.72xa0days in the open group, pu2009=u20090.529). An analysis based on the intention-to-treat with laparoscopy, including converted cases in the laparoscopic group, showed similar results, including overall complication rate (48.6 vs. 45.6%, pu2009=u20090.68) and Clavien–Dindo score in both minor (pu2009=u20090.24) and major complications (pu2009=u20090.44). Length of stay (10.92 vs. 11.81 days, pu2009=u20090.45) was also similar between the two groups.ConclusionIn this series, a laparoscopic approach to Hartmann’s reversal did not offer any short-term advantage when compared to an open surgical approach.

Considerations for Hartmann’s reversal and Hartmann’s reversal outcomes—a multicenter study

PurposeHartmann’s procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann’s procedure and evaluated factors affecting decision-making.MethodsData on patient demographics, comorbidities, causes for Hartmann’s procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann’s procedure in five medical centers.ResultsSix hundred forty patients underwent Hartmann’s procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (Pxa0=xa00.02), patient age (62.3xa0years in Hartmann’s reversal patients vs 73.5xa0years in non-reversal patients; Pxa0<xa00.0001), number of comorbidities (1.1 vs 1.58; Pxa0<xa00.001), average Charlson score (1.93 vs 3.44; Pxa0<xa00.001), and a neoplastic etiology (Pxa0<xa00.0001). A sub-analysis excluding all patients who died in the 30xa0days following Hartmann’s procedure showed similar factors associated with ostomy closure.ConclusionMany patients do not have restoration of bowel continuity after undergoing Hartmann’s procedure. Hartmann’s reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.