Ugo Cioffi

Randomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse

BACKGROUND This randomized prospective study compared the outcome of circular hemorrhoidectomy according to the Hospital Leopold Bellan (HLB) technique (Paris) with Longo stapled circumferential mucosectomy (LSCM) in two homogeneous groups of patients affected by circular fourth-degree hemorrhoids with external mucosal prolapse. METHODS From December 1996 to December 1999, 80 consecutive patients with fourth-degree hemorrhoids and external mucosal prolapse were randomly assigned to two groups. Forty patients (group A: 18 men, 22 women, mean age 50.5 years, range 21 to 82) underwent HLB hemorrhoidectomy, and 40 patients (group B: 15 men, 25 women, mean age 51.0 years, range 29 to 92) underwent LSCM. Before surgery, all patients were selected with a standard questionnaire for symptom evaluation, full proctological examination, flexible rectosigmoidoscopy, dynamic defecography, and anorectal manometry. No significant differences among the two groups were found. All patients were controlled with follow-up questionnaire and with clinical examination at 1, 2, 4, 12, and 54 weeks after the operation. A postoperative manometry was performed 3 months after surgery. RESULTS The length of the operation was significantly lower in group B (25 +/- 3.1 SD versus 50 +/- 5.3 minutes, P <0.001). Mean hospital stay was 3 +/- 0.4 days in group A and 2 +/- 0.5 days in group B (P <0.01). Mean duration of inability to work was 8 +/- 0.9 days in group B and 15 +/- 1.4 days in group A (P <0.001). Postoperative pain was significantly lower in group B (P <0.001). Mean length of follow-up was 20 +/- 8.0 months in group A and 20 +/- 7.8 months in group B. Late complications were similar in the two groups, with 0%, at present, recurrence rate. CONCLUSIONS Our results confirm that both operations are safe, easy to perform, and effective in the treatment of advanced hemorrhoids with external mucosal prolapse. However, the LSCM seems to be preferable owing to the fewer postoperative complications, easier postoperative management, and shorter time to return to work. A longer follow-up is required to confirm the true efficacy of this surgical method.

Value and limits of endorectal ultrasonography for preoperative staging of rectal carcinoma

In rectal cancer, the depth of tumor infiltration and metastatic involvement of lymph nodes are important prognostic factors. Endosonography of the rectum, combining the advantages of both endoscopy and sonography, provides information not available from other imaging diagnostic techniques. From January 1989 to December 1997, 85 patients affected by rectal carcinoma were submitted to preoperative evaluation with endorectal ultrasonography. In 75 cases the results obtained with the endosonography were compared to the histology of the resected specimens. Overall accuracy in staging depth of infiltration was 90.7%. Overstaging occurred in 4% of patients, whereas understaging occurred in 5.3%. In staging lymph nodal involvement, overall accuracy was 76%, sensitivity was 69.8%, specificity was 84.4%, positive predictive value was 85.7%, and negative predictive value was 67.5%. Endorectal ultrasound is a safe and accurate diagnostic method for staging both tumor invasion and lymph node metastatic involvement, and for selecting an appropriate surgical strategy in patients affected by rectal cancer.

Comparison of laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse: clinical and functional results.

The aim of this retrospective study was to compare the functional and clinical results of laparoscopic rectopexy with those of the open technique in two similar groups of patients with complete rectal prolapse and fecal incontinence. Between November 1992 and June 1997, 21 patients underwent abdominal rectopexy. Thirteen patients (group A: 12 women and 1 man, mean age 52.9 years, range 28-70) and 8 patients (group B: 8 women, mean age 58.2 years, range 20-76) were submitted to Wells rectopexy by the open technique and the laparoscopic approach, respectively, without division of the lateral rectal ligaments. Assignment to each group was done randomly. Before the operation, a detailed clinical history was taken, and patients were studied with inspection and digital examination of the anorectum, proctosigmoidoscopy, determination of pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography. After the operation, all patients underwent perineal physiotherapy, external electric stimulation, and perineal biofeedback. The mean follow-up time was 29.5 months (range 6-54) in group A and 25.7 months (range 8-45) in group B. Values were compared by chi-square, Mann-Whitney U, and Wilcoxon tests, as appropriate; differences were considered significant at p < 0.05. In both groups, dyschezia and fecal incontinence improved significantly (p < 0.05) after the operation. Basal pressure of anal sphincter, squeezing pressure, and rectoanal reflex improved without significance, whereas anoperineal pain was not significantly reduced. In group B, the postoperative hospital stay was shorter than in group A, with a marked reduction of costs. Laparoscopic Wells rectopexy has the same clinical and functional results as the open technique, with a shorter postoperative hospital stay and lower costs.

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.

Analgesia in patients undergoing thoracotomy: Epidural versus paravertebral technique. A randomized, double-blind, prospective study

BACKGROUND Pain control after thoracotomy prevents postsurgical complications and improves respiratory function. The gold standard for post-thoracotomy analgesia is the epidural catheter. The aim of this study was to compare it with a new technique that involves placement of a catheter in the paravertebral space at the end of surgery under a surgeons direct vision. METHODS From November 2011 to June 2012, 52 patients were randomized into 2 groups depending on catheter placement: an epidural catheter for group A and a paravertebral catheter for group B. At 12, 24, 48, and 72 hours after surgery, the following parameters were recorded: (1) pain control using the patients completion of a visual analog scale module, (2) respiratory function using forced expiratory volume in 1 second and ambient air saturation, and (3) blood cortisol values as an index of systemic reaction to pain. RESULTS Statistically significant differences (P < .05) were found in favor of group B for both cough and rest pain control (P = .002 and .002, respectively) and respiratory function in terms of forced expiratory volume in 1 second and ambient air saturation levels (P = .023 and .001, respectively). No statistically significant differences were found in blood cortisol trends between the 2 groups (P > .05). Collateral effects such as vomiting, nausea, low pressure, or urinary retention were observed only in group A. No collateral effects were recorded in the paravertebral group. CONCLUSIONS According to our data, drugs administered through a paravertebral catheter are very effective. Moreover, it does not present contraindications to its positioning or collateral effects. More studies are necessary to confirm data we collected.

Synchronous adenocarcinoma and carcinoid tumor of the terminal ileum in a Crohn's disease patient

BackgroundSeveral malignancies have been described in association with inflammatory bowel diseases, the most common being adenocarcinoma. Carcinoid tumor and Crohn disease has also been previously reported, however the coexistence of both neoplasms is quite rare and the clinical diagnosis is very difficult. Here we report what we believe to be the fourth case of a mixed adenocarcinoid tumor coexisting with Crohns disease.Case reportThe patient presented with clinical and radiological features of intestinal obstruction. Laparotomy showed a stricturing lesion in the last 6 cm of the terminal ileum with proximal dilation. Only the histology of the resected surgical specimen proved the presence of a mixed adenocarcinoid tumor involving the terminal ileum.ConclusionCarcinoid tumor should be suspected in elderly patients with Crohns disease presenting with intestinal obstruction and laparotomy should be considered to exclude malignancy.

Poorly differentiated carcinoma arising from adenolymphoma of the parotid gland

BackgroundThere is only one previous case report of a poorly differentiated carcinoma arising from an adenolymphoma of the parotid gland (Warthins tumour). The absence of clinical symptoms, and the aspecificity of the radiological pattern make the diagnosis very difficult.Case presentationWe here report the case of a 73-year-old man with Warthins tumour who was brought to our attention because of a swelling in the parotid region.ConclusionsIn this case with an atypical clinical presentation, the intra-operative examination of a frozen section of the parotid mass allowed us to diagnose the malignant tumour correctly and consequently undertake its radical excision.

Isolated Splenic metastasis from gastric carcinoma : Value of CEA and CA 19-9 in early diagnosis : Report of two cases

We report two cases of an isolated splenic metastasis, occurring 5 and 3 years, respectively, after gastrectomy for gastric carcinoma. Serum carcinoembryonic antigen and CA 19-9 levels were evaluated preoperatively, postoperatively, and during the oncologic follow-up. The patients underwent splenectomy for solitary splenic metastasis. We conclude that the use of serum carcinoembryonic and CA 19-9 values may help in the early diagnosis of these recurrences and splenectomy allows radical treatment in patients with no evidence of disseminated disease.

Solitary fibrous tumor of the pleura presenting with syncope episodes when coughing

BackgroundSolitary fibrous tumor of the pleura is a rarely encountered clinical entity which may have different clinical pictures. Although the majority of these neoplasms have a benign course, the malignant form has also been reported.Case presentationWe herein describe a case of 72 year-old man with head, facial, and thoracic traumas caused by neurally-mediated situational syncope when coughing. The diagnostic work-up including chest x-ray, CT and PET, revealed a large solitary mass of the left hemithorax. Radical surgical resection of the mass was performed through a left lateral thoracotomy and completed with a wedge resection of the lingula. Hystological examination of the surgical specimen showed an encapsulated mass measuring 12 × 11.5 × 6 cm consistent with a solitary fibrous tumor of the pleura. Its surgical removal definitively resolved the neurologic manifestations. The patient had no postoperative complications. At two years follow-up the patient is free from recurrence and without clinical manifestations.ConclusionIn our case its resection definitively resolved the episodes of situational syncope due, in our opinion, to the large thoracic mass compressing the phrenic nerve