Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial

AIM

This multicentre study, based on the largest patient population ever published, aims to evaluate the efficacy of Doppler-guided transanal haemorrhoidal dearterialization (THD Doppler) in the treatment of symptomatic haemorrhoids and to identify the factors predicting failure for an effective mid-term outcome.

METHOD

Eight hundred and three patients affected by Grade II (137, 17.1%), III (548, 68.2%) and IV (118, 14.7%) symptomatic haemorrhoidal disease underwent THD Doppler, with a rectal mucopexy in patients with haemorrhoidal prolapse. The disease was assessed through a specifically designed symptom questionnaire and scoring system. A uni- and multivariate analyses of the potential predictive factors for failure were performed.

RESULTS

The morbidity rate was 18.0%, represented mainly by pain or tenesmus (106 patients, 13.0%). Acute bleeding requiring surgical haemostasis occurred in seven patients (0.9%). No serious or life-threatening complications occurred. After a mean follow-up period of 11.1 ± 9.2 months, the overall success rate was 90.7% (728 patients), with a recurrence of haemorrhoidal prolapse, bleeding, and both symptoms in 51 (6.3%), 19 (2.4%) and 5 (0.6%) patients, respectively. Sixteen out of 47 patients undergoing re-operation had a conventional haemorrhoidectomy. All the symptoms were significantly improved in each domain of the score (P < 0.0001). At multivariate analysis the absence of morbidity and performance of a distal Doppler-guided dearterialization were associated with a better outcome.

CONCLUSION

THD Doppler is a safe and effective therapy for haemorrhoidal disease. If this technique is to be employed, an accurate distal Doppler-guided dearterialization and a tailored mucopexy are mandatory to contain and reduce the symptoms.

Estimation of prenatal aorta intima-media thickness from ultrasound examination

Prenatal events such as intrauterine growth restriction and increased cardiovascular risk in later life have been shown to be associated with an increased intima-media thickness (aIMT) of the abdominal aorta in the fetus. In order to assess and manage atherosclerosis and cardiovascular disease risk in adults and children, in recent years the measurement of abdominal and carotid artery thickness has gained a growing appeal. Nevertheless, no computer aided method has been proposed for the analysis of prenatal vessels from ultrasound data, yet. To date, these measurements are being performed manually on ultrasound fetal images by skilled practitioners. The aim of the presented study is to introduce an automatic algorithm that identifies abdominal aorta and estimates its diameter and aIMT from routine third trimester ultrasonographic fetal data.The algorithm locates the aorta, then segments it and, by modeling the arterial wall longitudinal sections by means of a gaussian mixture, derives a set of measures of the aorta diameter (aDiam) and of the intima-media thickness (aIMT). After estimating the cardiac cycle, the mean diameter and the aIMT at the end-diastole phase are computed.Considering the aIMT value for each subject, the correlation between automatic and manual end-diastolic aIMT measurements is 0.91 in a range of values 0.44-1.10 mm, corresponding to both normal and pathological conditions. The automatic system yields a mean relative error of 19%, that is similar to the intra-observer variability (14%) and much lower that the inter-observer variability (42%).The correlation between manual and automatic measurements and the small error confirm the ability of the proposed system to reliably estimate aIMT values in prenatal ultrasound sequences, reducing measurement variability and suggesting that it can be used for an automatic assessment of aIMT.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

BACKGROUND

The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR).

METHODS

Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity.

RESULTS

There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07).

CONCLUSION

Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

Cortisol response to an acute injection of IL-2 in healthy subjects and cancer patients: a first immunoneuroendocrine standardized clinical test to explore the interactions between immune and neuroendocrine systems

Preliminary clinical studies would suggest that the immune alterations characterizing severe human illnesses, such as autoimmune diseases and cancer itself, may depend at least in part on an anomalous psychoneuroendocrine regulation of the immunity. Unfortunately, at present the psychoneuroimmune interactions may be clinically investigated only by separately analyzing the neuroendocrine and the immune systems, since there is no standardized clinical test capable of detecting the physiological response of the endocrine secretion to an immune stimulation. One of the main endocrine functions influenced by the immune activation is the hypothalamic-pituitary-adrenal axis. In fact, several cytokines have appeared to stimulate cortisol secretion by acting at a central site. On this basis, a study was planned to evaluate cortisol response to an acute IL-2 injection in healthy subjects and metastatic cancer patients, in an attempt to standardize a clinical neuroendocrinoimmune test capable of documenting possible alterations of the link between neuroendocrine and immune systems. The study included 10 healthy subjects as a control group and 10 cancer patients with metastatic disease. Control subjects were evaluated in basal conditions to determine the physiological circadian rhythm of cortisol, and after the subcutaneous (SC) injection of IL-2 (3 and 9 million IU). IL-2 at 3 million IU stimulated cortisol release in all healthy controls and in none of the cancer patients. IL-2 at 9 million IU induced a significant increase in cortisol mean levels in cancer patients, whose values, however, were still significantly lower with respect to those seen in controls in response to IL-2 at 3 million IU. No important IL-2 related side-effect occurred. This study shows that an acute SC injection of low-dose IL-2 with a following evaluation of cortisol secretion may constitute a first standardized immunoendocrine test, capable of exploring the status of the physiological link between neuroendocrine and immune systems, and of documenting the existence of important alterations in human diseases related to an immune dysfunction, such as advanced cancer, which has appeared to be characterized by a hyposensitivity of the hypothalamic-pituitary-adrenal axis to an acute cytokine administration.

One-leg standing balance and functional status in an elderly community-dwelling population in northeast Italy

BACKGROUND AND AIMS

Development of simple and accurate indicators of frailty is an important research goal in aging societies. One-leg standing balance (OLSB) has been proposed as a component of a clinical index of frailty.

METHODS

We analyzed relationships between results of OLSB testing and multiple health risk factors and impairment/disability indicators in a sample of elderly subjects (N=102) participating in the Anchyses Project. Subjects were aged >65, lived in a home for the aged in Rovigo, Italy, and had no ADL dependencies or recent acute illnesses.

RESULTS

More than half (53%) failed the OLSB test while 36% were able to balance without difficulty. Significant differences were observed among OLSB performance groups in forced vital capacity (p=0.025), dynamometry (p=0.001), age, physical activity, and IADL dependency (all p<0.001).

CONCLUSIONS

OLSB performance is a marker of frailty and thus a potentially useful predictor of functional decline.

[Our experience with the use of Absolok polydioxanone resorbable clips in laparoscopic surgery]

BACKGROUND

The study aims to evaluate the efficacy of resorbable clips in polydioxanone in laparoscopic surgery.

METHODS

The authors report their personal experience regarding the use of Absolok (ABL) resorbable clips in laparoscopic surgery. Out of a total of 745 laparoscopic operations performed from September 1992 to February 1997, 438 included the use of resorbable clips in place of metal clips, both for cystic duct section during cholecystectomy and vascular structures, or to lock continuous sutures. ABL clips were also used for major vessels (e.g. mesenteric artery) during laparoscopic colic resections.

RESULTS

In all cases when they were used, ABL never gave rise to complications, such as biliary outflow or hemorrhage caused by the dislocation of the clips themselves.

CONCLUSIONS

The authors conclude by affirming the value and safety of this type of clip.

Conservative laparoscopy in the treatment of posttraumatic splenic laceration using microfiber hemostatic collagen: three case histories

Three cases of posttraumatic splenic laceration in young patients are reported. In each case, hemostasis of the lesion was obtained by the use of microfiber collagen in emergency laparoscopy. In two cases, complete hemostasis was achieved and the entire organ was saved. In the third case, splenectomy proved necessary after renewed bleeding occurred.

Ileal volvulus on internal hernia following left laparoscopic-assisted hemicolectomy

Described here is a case of constriction of the ileal loop caused by a volvulus forming on an internal hernia through the mesenteric opening in the anastomotic colonic stumps, following left laparoscopic-assisted hemicolectomy. This experience indicates the need for closure of mesenteric gaps with a continuous suture after laparoscopic-assisted left hemicolectomy.

Different pathways of apoptosis revealed by 2-chloro-adenosine and deoxy-D-ribose in mammalian astroglial cells

Both the adenosine analogue 2-chloro-adenosine (2-CA) and the reducing sugar deoxy-D-ribose (dRib) induce apoptosis of astroglial cells in rat brain primary cultures (Abbracchio et al.: Biochem Biophys Res Commun 213:908-915, 1995). The present study was undertaken to elucidate by both morphological and cytofluorimetric analyses the intracellular mechanism(s) involved in induction of apoptosis by these two agents. The poly(ADP-ribose)polymerase (PARP) inhibitor 3-aminobenzamide did not prevent either 2-CA- or dRib-induced cell death, suggesting that activation of PARP is not critically important for induction of apoptosis in astrocytes. The radical scavenger N-acetyl-cysteine (NAC) strongly inhibited dRib- but not 2-CA-induced cell death, suggesting a differential role for radical formation in apoptosis by these two agents. A time-dependent increase of cells with depolarized mitochondria was observed in dRib-, and to a lesser extent, in 2-CA-treated cultures. NAC also prevented dRib- but not 2-CA-induced mitochondrial changes. We conclude that, in mammalian astrocytes, apoptosis can proceed through diverse and multiple pathways, depending upon the apoptotic stimulus. For dRib, apoptosis likely proceeds through generation of radicals and mitochondrial involvement. An adenosine extracellular receptor linked to an as yet unidentified signaling pathway may instead mediate 2-CA-induced cell death, which may have intriguing implications for both nervous system development and brain response to trauma and ischemia.

[The varicocele today (anatomic and physiopathologic aspects)]

Primary varicocele is a very important clinical form in establishing of male infertility. It's origin is'nt ever caused by anatomical alterations of internal spermatic vein. Clinical picture is always joined with histopathological alterations of various degree, which, partial and in concomitance with hemodynamic disorders, explains the arising of spermatogenesis alterations.

[Malignant tumors of the breast: instrumental diagnosis]

Nowadays mammary cancer is still the principal cause of neoplastic deaths of females. Early diagnosis, through the complementary use of the various diagnostic techniques, is fundamental to improve the prognosis.

[Diagnostic use of angiography]

The angiography, in particularly after the introduction of the digitalized technique, results a method of considerable importance, whether for a more precise definition of the sort and nature of the lesion, or, above all, for a precise preoperating balance. The statement of hits utilization of screening test, is to be refused.

[Hemorrhagic pancreatic pseudocysts caused by erosion of the superior mesenteric artery]

The authors report a case of hemorrhage for upper mesenteric artery erosion secondary to a pancreatic pseudocyst. After a review of literature data they outline the possible causes regarding the hemorrhagic event in course of pseudocyst and the modalities it happens. They finally underline the importance of a precocious diagnosis concerning the hemorrhage kind and seat through selective angiography, for an opportune and rational surgical management.

[Palliative treatment of esophageal cancer]

The AA. describe the indications, the technique and the complications of application of oesophageal endoprosthesis (Celestin or Haring) for palliative treatment of oesophageal cancer and they value the results of 34 applications of these prosthesis that were executed about Surgical Clinic in Verona with satisfactory results during the period 1974-77. They show the improvement of survival conditions in these patients, the rareness of complications, the absence of absolute contra-indications.