A randomised trial comparing submucosal haemorrhoidectomy with radiofrequency bistoury vs. diathermic haemorrhoidectomy

BACKGROUND

Haemorrhoid disease has become more and more frequent during the past years among western populations. Great attention has been paid in development of surgical procedures, in order to reduce post-operative pain (the main adverse effect of surgical treatment for haemorrhoids) and shorten execution time and hospital stay. This randomised clinical study compares the results obtained using submucosal haemorrhoidectomy with radiofrequency vs. diathermic haemorrhoidectomy.

METHODS

Thirty-one patients were randomised to undergo submucosal haemorrhoidectomy with radiofrequency bistoury (16 patients, Group A) or diathermic haemorrhoidectomy (15 patients, Group B). The operating time, amount of pain and postoperative analgesic requirement, intra and post-operative complications and patient satisfaction were documented.

RESULTS

The mean values for operative time have been 35.8 min for group A and 23.2 min for group B. According to pain score, patients' mean values for first day postoperative pain were 3.8 (A) and 5.8 (B). Pain at first evacuation 4.7 (A) and 6.5 (B). Pain at 7th postoperative day was 2.3 (A) and 3.7 (B). Patient's postoperative satisfaction rate was 6.0 (A) vs. 5.2 (B) at 3rd day and 6.7 (A) and 5.7 (B) at 6 months.

CONCLUSIONS

In spite of relatively difficult execution and longer operating times, submucosal haemorrhoidectomy with radiofrequency bistoury appears to be the most precise and accurate treatment for IV degree haemorrhoids. Performing submucosal haemorrhoidectomy with radiofrequency bistoury allows us to reduce postoperative pain, bleeding and shorten hospital stay.

Pyloric atresia: a new operation to reconstruct the pyloric sphincter

BACKGROUND/PURPOSE

The standard method of surgical correction of pyloric atresia "solid segment" type is a gastroduodenostomy that can in the long term cause bilious duodenogastric reflux. The authors report 2 cases of pyloric atresia in which the pyloric sphincter was reconstructed by a new technique of gastroduodenal mucosal advancement anastomosis.

METHODS

Two premature babies with "solid segment"-type pyloric atresia, one with an associated junctional epidermolysis bullosa, underwent surgery for reconstruction of the pyloric sphincter. By a longitudinal incision of the atretic pylorus, the cul-de-sacs of gastric and duodenal mucosa were isolated in the respective gastric and duodenal sides, advanced into the opened pyloric canal, and sutured together using end-to-end anastomosis. The longitudinal pyloromyotomy then was closed above the reconstructed mucosal pyloric neocanal.

RESULTS

The postoperative course was normal. At 7 years (patient 1) and 2 years (patient 2) after the operation, both are well, and no gastrointestinal disorders are present. Good competence of the pyloric sphincter has been confirmed by x-ray barium meal in both cases, and by HIDA technetium 99m hepatic scintiscan and esophagogastroduodenoscopy (EGD) with biopsy in patient 1.

CONCLUSIONS

Our technique of surgical correction of pyloric atresia allows preservation of the pyloric sphincter, whose muscular layer, although hypoplastic, is present in these cases.

Apoptosis of crypt cells and lymphocytes in gut-associated lymphoid tissues during small intestinal graft rejection in rats

INTRODUCTION

We investigated the extent of apoptosis in crypt cells and Peyer's patches (PPs) during small bowel allograft rejection in rats to examine whether the Fas/FasL pathway participates in apoptosis within grafts during rejection.

MATERIALS AND METHODS

Orthotopic small bowel transplantation with portocaval drainage was performed from Brown Norway to Lewis (LEW) rats. Isografted (LEW --> LEW) and nontransplanted animals served as the controls. Animals were sacrificed on days 3, 5, on 7 after SBT (each n = 5). An in situ end-labeling (ISEL) technique was used to detect apoptotic cells. Indirect immunoperoxidase staining was also performed using monoclonal antibodies against rat Fas or Fas-L.

RESULTS

The number of ISEL-positive enterocytes in the allografts increased significantly on days 3, 5, and 7. Similarly, in the PPs of the allografts, the number of ISEL-positive mononuclear cells increased significantly on days 3, 5, and 7. On day 7 the number of Fas- and FasL-positive enterocytes were increased significantly in the allografts compared with the nontransplanted controls. Similarly, in the PPs, Fas- and FasL-positive mononuclear cells also increased significantly on day 7 in the allograft.

CONCLUSION

Although an increase, number of apoptotic enterocytes and lymphocytes were observed in the early phase, activation of Fas/FasL system occurred during the late phase of small bowel graft rejection. These findings suggest that both rejection-associated and sepsis-induced forms of apoptosis may be associated with small bowel graft rejection.

Impact of miniprobe ultrasonography on planning of minimally invasive surgery for gastric and colonic tumors

BACKGROUND

The use of minimally invasive procedures for the management of gastrointestinal cancer is increasing. The aim of this study was to investigate the role of high-frequency miniprobe endoscopic ultrasound (EUS) for therapeutic decisions making in patients with gastric or colonic tumors.

METHODS

A total of 137 patients underwent EUS with a 12.5-MHz miniprobe for preoperative staging of tumors of the stomach ( n = 49) or colon ( n = 88). After resection, the surgical path was reviewed to analyze the role of preoperative staging with miniprobes.

RESULTS

Miniprobe EUS enabled accurate assessment of the infiltration depth of gastric and colonic tumors. The overall accuracy rates were 88% and 87%, respectively. The lymph node status was predicted correctly in 82% of the patients (sensitivity, 61%, specificity, 94%). Based on the results of miniprobe EUS, patients with gastric cancer were accurately selected to undergo endoscopic mucosal resection, laparoscopic resection, or open surgery in 100%, 91%, and 86% of the cases, respectively. In patients with colonic tumors, the treatment decision analysis showed that the stratification was correct in 90% of the patients.

CONCLUSIONS

Miniprobe EUS is a reliable method for validating treatment decisions for patients undergoing minimally invasive procedures for gastric and colonic tumors. This method is particularly valuable in the management of colon cancer, because endoscopic and laparoscopic resections can be offered to selected patients as an alternative to open surgery.

Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial

BACKGROUND

Anastomotic failure is still a significant problem that affects the outcome of pancreaticoduodenectomy. There have been many techniques proposed for the reconstruction of pancreatic digestive continuity, but there have been few prospective and randomized studies that compare their efficacy.

METHODS

In the current work, 144 patients who underwent a pancreaticoduodenectomy with soft residual tissue were assigned randomly to receive either a duct-to-mucosa anastomosis (group A) or a 1-layer end-to-side pancreaticojejunostomy (group B).

RESULTS

The 2 treatment groups were found not to have any differences in regards to vital statistics, underlying disease, or operative techniques. The postoperative course was complicated in 54% of the 144 patients, with a comprehensive incidence of abdominal complications in 36% (group A, 35%; group B, 38%; P=not significant). The principal complication was pancreatic fistulas, which occurred in 14% of patients (group A, 13%; group B, 15%; P=not significant). Two patients (2%) required reoperation; the postoperative mortality rate was 1%.

CONCLUSION

The 2 methods that were studied revealed no significant difference the rate of complications.

[Analysis of causes of unsatisfactory results of rectocele surgical treatment and ways of their correction]

Causes of recurrences and unsatisfactory results of rectocele surgical treatment (except wound suppuration after surgery) were analyzed. It was concluded that prolapse of rectal mucosa and (or) severe muscular atrophy of the pelvic fundus uncorrected during transvaginal correction of rectocele are the main causes. It is recommended to resect mucosal excess by a traditional or A. Longo's method in the former case and to use synthetic net in the latter. This brings about favorable results in these patients.

[Prolassomucosectomy according to Longo. Intermediate results]

We present results obtained in our first series of 25 patient treated by prolassomucosectomy for haemorrhoidal prolapse with a follow up of 18-36 months. Control of the disease and functional results proved to be optimal. After small early haemorrhages from the suture line, we started adding stitch sutures with haemostatic intent to all three vascular pedicles. Early or late additional complication were not observed.

[One-stage urethroplasty using colonic mucosa in the treatment of complex lengthy urethral stricture]

OBJECTIVE

To investigate the feasibility of urethral reconstruction with colonic mucosa graft in the treatment of complex lengthy urethral stricture.

METHODS

Between October 2000 and May 2003, 19 male patients with complex lengthy urethral stricture that had undergone unsuccessful urethral repair 3 times on average, aged 18 - 65, were treated with free graft of colonic mucosa 10 to 17 cm (mean 13.2 cm) long. The patients were followed-up for 6 - 36 months (17 months on average) by retrograde urethrography, urethroscopy, and uroflometry.

RESULTS

Meatal stenosis that needed reoperation was developed in 1 patient 3 months postoperatively. This patient became voiding very well with a urinary peak flow of 28.7 ml per second during the follow-up of 12 months after the second operation. Hyperplasia of verumontanum was observed during urethroscopy in 1 patient 14 months postoperatively. Uroflometry examination showed a urinary peak flow of 46.5 ml/s after transurethral colliculectomy. The other 17 patients were voiding well with a urinary peak flow greater than 15 ml/s (16 to 28.5 ml/s).

CONCLUSION

Colonic mucosa graft urethroplasty is a feasible procedure for the treatment of complex lengthy urethral stricture, particularly when the more conventional options fail or are contraindicated.

Pedunculated rectal carcinoid removed by endoscopic mucosal resection: a case report

Carcinoid tumors generally appear as yellow/gray or tan submucosal nodules. We experienced a case of pedunculated rectal carcinoid showing a mushroom-like appearance. The case was a forty years old woman who was admitted to our hospital due to rectal bleeding. Colonoscopy revealed a pedunculated polyp presenting a mushroom-shaped appearance measuring 13 mm in diameter in the rectum. The histological diagnosis of specimens obtained by biopsy was adenocarcinoma and transanal ultrasonography revealed the tumor localization within the submucosal layer in the rectum. Endoscopic mucosal resection (EMR) was performed. Histopathological examination established the diagnosis of carcinoid tumor in the rectum. Frequencies of the pedunculated type in rectal carcinoids were reported to be 2.4% to 7.1% in the literature. Because of its rarity, pedunculated configuration may confuse the endoscopic diagnosis of carcinoids. Treatment for carcinoids of 1 to 1.5 cm in size remains controversial. Although such tumors are technically respectable by EMR, careful attention must be paid in dealing with these tumors because there may be unexpected behaviors of the tumors.

Argon plasma coagulation of hemorrhagic solitary rectal ulcer syndrome

Solitary ulcer syndrome (SUS) is a rare disorder that may provoke hematochezia. Argon plasma coagulation (APC) is used in a wide range of gastrointestinal bleeding. We experienced APC in a patient with a bleeding gigantic SUS: a 64-year-old woman who developed a SUS at 60. After 3 years, recurrent hematochezia, secondary anemia, and rectal pain occurred. Endoscopy revealed a large rectal bleeding ulcer. Moreover, the pain led the patient to assume analgesics. These conditions stimulated us to treat this ulcer with APC within 4 sessions; each session spaced out at 30-day intervals. The patient experienced and maintained the following benefits: (1) resolution of bleeding and secondary anemia after the first session, (2) reduction of ulcer depth, disappearance of pain and analgesic withdrawal at the end of the cycle, (3) almost complete endoscopic healing of the ulcer after 9 months of follow-up. This experience suggests that APC may represent a therapeutic approach for bleeding SUS even if controlled studies are necessary before recommending it as acceptable treatment.

Endoscopic mucosal resection of superficially spreading colonic neoplasms larger than 5 cm in the right colon after injection of dilute sodium hyaluronate: report of two cases

Submucosal injection is the most important procedure for the safe performance of endoscopic mucosal resection in the large intestine while avoiding the risk of perforation. We used dilute sodium hyaluronate containing Bosmin and achieved safe piecemeal resection of large superficial tumors in the right colon in two patients. Piecemeal snare resection is considered to be acceptable if all the tissue pieces can be collected for histopathological diagnosis.

Clinicopathologic features and endoscopic resection of early primary nonampullary duodenal carcinoma

Early primary nonampullary duodenal carcinoma is an extremely rare disease with poorly defined clinicopathologic features; early detection of this carcinoma is not common. To clarify the clinicopathologic characteristics of early primary nonampullary duodenal carcinoma and retrospectively analyze methods of treatment. Seventeen early duodenal carcinomas identified between 1994 and 2001 in 15 patients were studied. Lesions were divided into 2 groups: sporadic carcinoma (10 cases in 10 patients) and familial adenomatous polyposis associated carcinoma (7 cases in 5 patients). Clinicopathologic features and methods of treatment were compared between groups. The mean age of patients with sporadic carcinoma (63.8 years) was significantly higher than that of patients with FAP-associated carcinoma (34.9 years). The incidence of sporadic carcinoma was significantly higher in men that in women (M:F ratio 9:1); the difference between sexes in the incidence of FAP-associated carcinoma (1:4) was not significant. There was no significant difference between both groups in relation to tumor size, location, gross appearance, or histopathology. Thirteen of the duodenal tumors were treated by endoscopic mucosal resection (EMR), two by polypectomy, and two by open surgery. Complications were encountered in 1 of 15 cases (6%); local bleeding occurred after one EMR, but hemostasis was achieved endoscopically. The mean follow-up period for all patients was 51.7 months. No patients experienced recurrence after resection. The significant differences between patients with sporadic and those with early FAP-associated duodenal carcinoma were in age and sex. Endoscopic resection appears to be a safe and efficient treatment of carefully selected patients with early primary nonampullary duodenal carcinoma.

Factors associated with ileal mucosal morphology and inflammation in patients with ileal pouch-anal anastomosis for ulcerative colitis

PURPOSE

Pouchitis has been associated with abnormal bacterial flora responding to antibiotics. Dietary factors may play a role in modifying the qualitative and quantitative components of the microflora. We evaluated interactions between nutritional factors, fecal and mucosal bacterial flora, and mucosal morphology in patients with a history of pouchitis compared with patients with optimal outcome at least five years after ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

Thirty-two patients were enrolled in the study: 11 (7 males; mean age, 49.8 years) with optimal outcome and 21 (11 males; mean age, 47.3 years) with pouchitis history. A seven-day food diary was recorded, endoscopy performed, and biopsies taken from the pouch for histology, mucin staining, and bacterial culture. Fresh fecal samples were quantitatively cultured, and fecal bile acids analyzed by gas-liquid chromatography.

RESULTS

No differences existed in mean nutrient intake, composition of fecal bile acids, or microbial tissue biopsy cultures between the groups with and without pouchitis. Those with optimal outcome tended to have more benign disease course of ulcerative colitis than patients with pouchitis. In those patients, fecal concentrations (log10 colony-forming unit/g) of anaerobes and aerobes were significantly higher (P = 0.007). Degree of villous atrophy and colonic metaplasia were both associated with fecal anaerobic flora. Low intake of lactose was associated with sulfomucin predominance. A negative correlation existed between fecal aerobes and dietary lactose consumption.

CONCLUSIONS

A higher total load of fecal anaerobic bacterial flora is strongly associated with degree of colonic metaplasia, villous atrophy, and inflammation activity after surgery for ulcerative colitis. An association existed between dietary lactose, fecal bacteria, and pouch morphology. Lactose may have prebiotic properties.

[Clinical study of 102 cases of abdominal-anus resection with telescopic anastomosis of colon rectal mucosa for lower segment of rectal cancer]

OBJECTIVE

To investigate the reliability and feasibility of abdominal-anus resection with preservation of anal sphincter by telescopic anastomisis of colon rectal mucosa for middle-lower segment of rectal cancer.

METHODS

A retrospective analysis was made for abdominal-anus resection with telescopic anastomosis of colon rectal mucosa in 102 cases of middle-lower segment of rectal cancer.

RESULTS

No anastomotic fistula and anastomotic stenosis occurred in the 102 cases. The increased defecation was found during early stage of postoperation, about 6-12 times per day. But this was easily controlled by antidiarrheal drugs. Twelve to 18 weeks later, defecation returned to normal. Follow-up was performed in 91 patients, and the follow-up rate was 89.2%. Mean follow-up period was 4.7 years. Local recurrence rate of the carcinoma was 5.4% (5/91), and hepatic metastasis rate was 13.1% (12/91). Three-year survival rate of postoperation was 86.9% (60/80), and five-year survival rate was 70.7% (29/41).

CONCLUSIONS

With telescopic anastomosis of colon rectal mucosa, colon stoma can be avoided, and anastomotic fistula can be prevented. The operation is safety and effective in preservation of anal sphincter for rectal cancer therapy.

Circumferential mucosectomy with stapled proctopexy is a safe, effective outpatient alternative for the treatment of symptomatic prolapsing hemorrhoids in the elderly

BACKGROUND

Circumferential mucosectomy with stapled proctopexy (CMSP) was first introduced in 1993 as a less painful and highly effective alternative to traditional operative hemorrhoidectomy. Although CMSP has many advantages over traditional hemorrhoidectomy, some authorities and insurers continue to regard it as an inpatient procedure and others have been slow to adopt this progressive technique. This study documents the safe and effective outpatient nature of this procedure.

METHODS

From December 2001 through August 2002, 33 patients with mucosal prolapse and prolapsing internal hemorrhoids were treated using circumferential mucosectomy with stapled proctopexy as outpatients at an ambulatory surgery center. Fourteen (42%) patients were treated using local anesthesia with intravenous sedation, 18 (55%) chose spinal anesthesia, and general anesthesia was used in one patient. Patients were evaluated postoperatively by telephone at 1 and 2 weeks, and seen in clinic at 4 weeks.

RESULTS

One patient (3%) required an emergency department visit for minor postoperative bleeding. None of our elderly patients required emergency department evaluation and none reported significant complications. Four patients (13%) required urinary catheter placement prior to discharge from the surgery center due to urinary retention. One patient (3%) developed an uncomplicated urinary tract infection, which resolved with antibiotic treatment. Two patients were seen earlier than 4 weeks at the surgeon's request; one was immunocompromised from chemotherapy for metastatic carcinoid, and one reported persistent pain during initial telephone follow-up. No complications were identified in either patient, and no additional complications have been noted to date.

CONCLUSIONS

CMSP is a safe, effective, time-efficient procedure for patients with mucosal prolapse and prolapsing hemorrhoids that can be performed safely in the ambulatory surgery center setting. Age is not a limiting factor in selecting patients for this safe outpatient procedure.

IGF-I augments resection-induced mucosal hyperplasia by altering enterocyte kinetics

Our objective was to determine if exogenous insulin-like growth factor-I (IGF-I) augments the adaptive growth response to mid small bowel resection in association with changes in enterocyte kinetics. We determined structural adaptation and concomitant changes in enterocyte proliferation, apoptosis, and migration of the jejunum in growing, parenterally fed rats after mid small bowel resection or small bowel transection, and treatment with IGF-I or vehicle. IGF-I treatment in resected rats significantly increased jejunal mucosal mass by 20% and mucosal concentrations of protein and DNA by 36 and 33%, respectively, above the response to resection alone. The enhancement of resection-induced adaptive growth and cellularity by IGF-I reflected an increase in enterocyte proliferation, an expansion of the proliferative compartment in the crypt, and no further decrease in enterocyte apoptosis or increase in enterocyte migration beyond the effects of resection. The ability of IGF-I to augment the mucosal hyperplasia stimulated by the endogenous response to resection substantiates the role of IGF-I as an intestinal mitogen that promotes tissue regeneration.

Does high-pressure carbon dioxide insufflation facilitate mucosal dissection in transanal endorectal pull-through? A rabbit model

The aim of the present study was to investigate whether high-pressure carbon dioxide insufflation facilitates mucosal dissection in the transanal endorectal pull-through (TEPT) operation performed in Hirschsprung's disease in a rabbit model. In the study, ten New Zealand rabbits were used. In six of the rabbits, CO(2) under 50 mmHg pressure was insufflated into the submucosal area through a 25-gauge scalp needle inserted 0.3 cm over the dentate line. Two of the rabbits were taken for histopathological examination. In four rabbits, the TEPT operation was performed and in another four the operation was performed without CO(2) insufflation. Histopathological examination in the CO(2)-insufflated group of rabbits showed that at transversal incisions mucosa was seen to be separated circumferentially from submucosa by high pressure CO(2) and at longitudinal incision the separation was seen to be complete along the anal canal. It was noted that mucosal dissection was rapid, non-bloody and without induced mucosal tears or perforation; however, in the non-insufflated group the operation was time-consuming, bloody and more difficult to perform and needed meticulous care. In the present study, it was seen that submucosal high pressure CO(2) insufflation in rabbits facilitates mucosal dissection in the TEPT operation and is easy to perform, time-saving and highly economical.

Mucosal plication (Gant-Miwa procedure) with anal encircling for rectal prolapse--a review of the Japanese experience

Although mucosal plication for rectal prolapse, known as the Gant-Miwa procedure, is described in some English textbooks, it has been infrequently performed in the West. However, this procedure has been used and developed in conjunction with anal encircling in Japan since the 1960s and is still considered to play a major role in the treatment of rectal prolapse. Certain technical details have been found necessary to ensure the success of the procedure, especially in the technique of anal encircling. For example, the use of Teflon tape and routing relatively deeply and outside the external anal sphincter are necessary. Clinical results show a recurrence rate of 0 to 31 percent with no mortality and almost never any serious complications such as significant bleeding or severe sepsis, which are occasionally encountered in other perineal procedures. Most patients report improved continence after this procedure, and worsening of evacuation is rarely encountered based on our experience. Some physiologic studies have shown improved resting pressure and rectal sensation, which can have a positive influence on the defecatory function. We believe that the Gant-Miwa procedure with anal encircling should be considered as a treatment of choice among perineal procedures for rectal prolapse.