Stapled hemorrhoidopexy: The Aga Khan University Hospital experience

BACKGROUND/AIM

Stapled hemorrhoidopexy for prolapsing hemorrhoids is conceptually different from excision hemorrhoidectomy. It does not accompany the pain that usually occurs after resection of the sensitive anoderm. This study was carried out to evaluate the clinical outcome of stapled hemorrhoidopexy at The Aga Khan University Hospital.

MATERIALS AND METHODS

A sample of 140 patients with symptomatic second-, third-, and fourth-degree hemorrhoids and circumferential mucosal prolapse underwent stapled hemorrhoidopexy from July 2002 to July 2007. They were evaluated for postoperative morbidity, analgesic requirement, and recurrence.

RESULTS

Seventy-eight percent were males and the mean age was 45 (range 16-90) years. The mean operative time was 35 (15-78) min. The mean parenteral analgesic doses during the first 24 h were 2.1. All patients received oral analgesics alone after 24 h. No significant postoperative morbidity was observed. The mean in-patient hospital stay was 1.3 (0-5) days. Patients were followed-up for 24 (range, 2-48) months. Minor local recurrence of hemorrhoids was seen in four patients and was managed by band ligation.

CONCLUSION

Stapled hemorrhoidopexy procedure was found safe, well tolerated by patients with minimal parenteral analgesic use and early discharge from the hospital.

A simple scoring system based on clinical features to predict locally advanced rectal cancers

PURPOSE

The purpose of this study was to identify clinical risk factors and establish a prediction scoring system for locally advanced rectal cancer.

MATERIALS AND METHODS

Retrospective univariate and multivariate logistic analyses were conducted for 413 curable rectal cancer patients. Clinical factors found to be significantly related with tumor stages were incorporated into a scoring system to predict locally advanced stages, which was validated in an independent cohort of 279 rectal cancer patients.

RESULTS

In the training set, tumor size, differentiation, and serum carcinoembryonic antigen (CEA) level (P < 0.01) were significant predictors of locally advanced rectal cancer in both univariate and multivariate analyses, which were incorporated into a proposed scoring system to predict locally advanced stages. The area under the receiver operating characteristic curve (AUROC) of this scoring system was 0.751 and the prediction accuracy was 78.2%. Patients were categorized into three subsets according to the total score. The low-risk group (score 0) had a smaller chance (18.2%) to have locally advanced rectal cancer, compared to mean 49.2% for the intermediate-risk group (score 1) and mean 83.0% for the high-risk group (score of 2-4; P < 0.05). In the validation set, the AUROC of the scoring system was 0.756 and the prediction accuracy was 75.3%.

CONCLUSIONS

Tumor size more than 2 cm, poor differentiation, and elevated serum CEA level are high-risk factors of locally advanced rectal cancer. A simple scoring system based on these three factors may be valuable to predict locally advanced rectal cancer.

Update on anesthetic management for pneumonectomy

PURPOSE OF REVIEW

Pneumonectomy has the highest perioperative risk among common pulmonary resections. The purpose of this review is to update clinicians on the importance of anesthetic management for these patients.

RECENT FINDINGS

Two complications associated with increased perioperative mortality are relevant to anesthetic management: postoperative arrhythmias and acute lung injury. The geriatric population is particularly at risk for arrhythmias. Adequate preoperative cardiac assessment and drug prophylaxis may decrease this risk. Patients with decreased respiratory function are at increased risk for acute lung injury. The use of large tidal-volume ventilation during anesthesia may increase this risk. There is a trend to better outcomes in centers with larger surgical volumes.

SUMMARY

Patients should have a preoperative assessment of their respiratory function in three areas: lung mechanical function, pulmonary parenchymal function and cardiopulmonary reserve. Interventions that have been shown to decrease the incidence of respiratory complications include cessation of smoking, physiotherapy and thoracic epidural analgesia. Extrapleural pneumonectomy and sleeve pneumonectomy are surgical variations that place specific increased demands on the anesthesiologist. The rare but treatable complication of cardiac herniation must always be remembered as a potential cause of life-threatening hemodynamic instability in the early postoperative period.

Immunohistochemical localization of mdm-2, p27Kip1 and bcl-2 in Warthin's tumor of the parotid gland

Background

Warthin's tumor is a benign monomorphic adenoma with unclear origin that almost occur exclusively in the parotid gland. Etiology of Warthin's tumor as well as its malignant potential are still unclear. Therefore immunohistochemical assessment of Warthin's tumor may be useful to detect its origin or its malignant transformation potential.

Aims and objectives

The present study aims to investigate the immunohistochemical expression of murine double minute-2 (mdm-2), p27^Kip1 and B cell lymphoma-2 (bcl-2) in Warthin's tumor of parotid gland and also to clarify the role of these proteins in the behavior of that tumor.

Methods

Twenty paraffin blocks of cases previously diagnosed as Warthin's tumor were collected for immunohistochemical staining with primary antibodies against mdm-2, p27^Kip1 and bcl-2 using streptavidin-biotin immunoperoxidase staining system.

Results

All cases showed immunopositivity for mdm-2 and p27^Kip1 while 18/20 showed bcl-2 immunopositivity. Both layers of the neoplastic epithelial cells that line the cystic spaces showed immunopositivity with all antibodies used. Goblet cells were mdm-2 immunonegative while myoepithelial cells were p27^Kip-1 immunonegative. Areas of epithelial proliferation that formed buds were p27^Kip-1 and bcl-2 immunopositive.

Conclusion

Mdm-2 played a tumor-suppressor role that might be implicated with the benign behavior of Warthin's tumor. The mutual expression of both p27^Kip1 and bcl-2 suggested a protective role of these slowly proliferating cells from apoptosis to maintain their survival and elevated bcl-2 expression offers a significant protection against p27^Kip1-mediated apoptosis.

Surgical treatment of anal stenosis

Anal stenosis is a rare but serious complication of anorectal surgery, most commonly seen after hemorrhoidectomy. Anal stenosis represents a technical challenge in terms of surgical management. A Medline search of studies relevant to the management of anal stenosis was undertaken. The etiology, pathophysiology and classification of anal stenosis were reviewed. An overview of surgical and non-surgical therapeutic options was developed. Ninety percent of anal stenosis is caused by overzealous hemorrhoidectomy. Treatment, both medical and surgical, should be modulated based on stenosis severity. Mild stenosis can be managed conservatively with stool softeners or fiber supplements. Sphincterotomy may be quite adequate for a patient with a mild degree of narrowing. For more severe stenosis, a formal anoplasty should be performed to treat the loss of anal canal tissue. Anal stenosis may be anatomic or functional. Anal stricture is most often a preventable complication. Many techniques have been used for the treatment of anal stenosis with variable healing rates. It is extremely difficult to interpret the results of the various anaplastic procedures described in the literature as prospective trials have not been performed. However, almost any approach will at least improve patient symptoms.

Left ventricle radio-frequency ablation in the rat: a new model of heart failure due to myocardial infarction homogeneous in size and low in mortality

BACKGROUND

The purpose of the current study was to create a model of myocardial infarction (MI) that is homogeneous in size with a low immediate (24 hours) mortality.

METHODS AND RESULTS

Male and female rats (n = 256) underwent left ventricle (LV) ablation (Ab) by a radiofrequency current (1000 kHz; 12 watts for 12 seconds) to promote a MI. A transmural MI occurred in all rats. Post-Ab complex arrhythmias were frequent (atrioventricular block, ventricular tachycardia, and fibrillation), which rapidly and spontaneously reverted to sinus rhythm. Among 66 male rats, immediate mortality occurred in 7.5%. Small MI size dispersion was characterized by smaller variability following Ab (x +/- SD: 45 +/- 8%) when compared with coronary occlusion (Oc; 40 +/- 19%). The histopathologic evaluations identified lesions similar to those which occurred following Oc, with scarring complete at 4 weeks. The hemodynamic and Doppler echocardiograms showed comparable increases in LV dimension, end-diastolic pressure, and pulmonary water content 1 and 4 weeks post-MI. Papillary muscle mechanics 6 weeks post-MI had matched inotropic and lusitropic dysfunction.

CONCLUSIONS

LV Ab gave rise to a MI within a narrow size limit and with a low immediate mortality. LV Ab resulted in histopathologic evolution, ventricular dilation, and dysfunction, impairment in myocardial mechanics, and congestive outcome that reproduced a MI from Oc.

Stomach cancer: prevalence and significance of neck nodal metastases on sonography

The aim of this study was to determine the frequency of metastatic neck nodes detected using sonography in patients with stomach cancer at presentation according to primary subsite and to assess the effect of metastatic neck node detection on tumour staging. Imaging and histological records of 233 patients diagnosed with stomach cancer were reviewed. All patients underwent neck ultrasound at presentation with ultrasound-guided fine needle aspiration for cytology (FNAC) of sonographically abnormal neck nodes. Abnormal nodes were classified positive or negative for metastases based on the FNAC result. Clinical records were also reviewed for evidence of subsequent neck nodal metastases. Sonographically abnormal neck nodes were present in 14/233 (6.0%) patients; 7 were reactive and 7 were metastatic based on FNAC findings and clinical follow-up. Overall, 7/233 (3.0%) patients with stomach cancer had nodal metastases, although tumour stage was altered in only 2/233 (0.9%) patients; 57% of metastatic nodes were impalpable. Nodal metastases from gastric cardia tumours (6%) were more common than from the body (2%) or antrum (3%). Neck node metastases are uncommon in stomach cancer at presentation, are usually associated with extensive intra-abdominal metastatic spread, and adversely influence tumour staging in only a small minority of patients.

Raquianestesia com morfina versus raquianestesia sem morfina associada a bloqueio do nervo pudendo: avaliação da analgesia e complicações em hemorroidectomias

INTRODUÇÃO: Recentemente, alguns autores têm relatado que o bloqueio do nervo pudendo com uso de ropivacaína proporciona boa analgesia pós-operatória. Assim, considerou-se de interesse a comparação de dois métodos anestésicos verificando a analgesia pós-operatória e as complicações. OBJETIVO: Comparar duas técnicas anestésicas (raquianestesia com morfina versus raquianestesia sem morfina associada com bloqueio do nervo pudendo) para hemorroidectomia quanto à analgesia pósoperatória e complicações. MATERIAIS E MÉTODOS: Foram estudados 40 pacientes provenientes do ambulatório de Coloproctologia do Hospital Regional de Mato Grosso do Sul no período de março a outubro de 2008. Todos os pacientes foram randomizados por sorteio imediatamente antes de se iniciar a intervenção cirúrgica e foram distribuídos em dois grupos: Grupo 1: 20 pacientes submetidos à raquianestesia com morfina com 0,15µg associado com bupivacaína hiperbárica 10mg; - Grupo 2: 20 pacientes submetidos à raquianestesia com bupivacaína pesada 10mg associado ao bloqueio do nervo pudendo bilateral com agulha para raquianestesia 27G utilizando ropivacaína 10mg/ml diluída em 10ml de água destilada. RESULTADOS: Avaliou-se 40 pacientes, sendo 21 do sexo feminino. A idade média foi de 52 anos, variando de 21 a 72 anos. Apenas no grupo 1 observou-se complicações, sendo a principal prurido, seguida de retenção urinária e cefaléia. Após 6 horas da cirurgia, a média do nível de dor foi 1,55 no grupo 1 e 1,4 no grupo 2. Após 12 horas da cirurgia as médias foram 1,75 e 0,15 nos grupos 1 e 2, respectivamente. CONCLUSÃO: A hemorroidectomia realizada com associação de raquianestesia sem morfina e bloqueio do nervo pudendo utilizando ropivacaína proporcionou melhor efeito analgésico no período de 12 horas após a cirurgia e não apresentou complicações nesta casuística, mostrando-se superior à raquianestesia com morfina.

Stapled haemorrhoidopexy compared to Milligan-Morgan and Ferguson haemorrhoidectomy: a systematic review

PURPOSE

The aim of this study was to perform a systematic review and meta-analysis of the short- and long-term outcomes of stapled haemorrhoidopexy.

METHODS

A literature search identified randomised controlled trials comparing stapled haemorrhoidopexy with Milligan-Morgan/Ferguson haemorrhoidectomy. Data were extracted independently for each study and differences analysed with fixed and random effects models.

RESULTS

Thirty-four randomised trials and two systematic reviews were identified, and 29 trials included. Stapled haemorrhoidopexy was statistically superior for hospital stay (p < 0.001) and numerically superior for post-operative pain (peri-operative and mid-term), operation time and bleeding (post-operative and long-term). Recurrent prolapse and re-intervention for recurrence were more frequent following stapled haemorrhoidopexy. No difference was observed in the rates of complications.

CONCLUSIONS

Stapled haemorrhoidopexy reduces the length of hospital stay and may have an advantage in terms of decreased operating time, reduced post-operative pain and less bleeding but is associated with an increased rate of recurrent prolapse.

Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review

OBJECTIVE

This systematic review aimed to evaluate the short- and long-term safety, efficacy and costs of stapled haemorrhoidopexy (SH) compared with conventional haemorrhoidectomy.

METHOD

We searched 26 electronic databases and websites for studies in any language up to July 2006. Inclusion criteria were predefined, and each stage of the review process was conducted in duplicate.

RESULTS

Twenty-seven randomized controlled trials were included (n = 2279). All had some methodological flaws. Postoperatively, 19 trials (95%) reported less pain, 17 (89%) reported a shorter operating time, 14 (88%) a shorter hospital stay, and 14 (93%) a shorter convalescence time following SH. However, prolapse was significantly more common after SH (OR 3.38; 95% CI: 1.00, 11.47). In the longer term, prolapse was significantly more common after SH (OR 4.34; 95% CI: 1.67, 11.28) as was reintervention for prolapse (OR 6.78; 95% CI: 2.00, 23.00). There were no differences in the rate or type of complications. Conventional haemorrhoidectomy and SH had similar costs during the initial admission.

CONCLUSION

Compared with conventional haemorrhoidectomy, SH resulted in less postoperative pain, shorter operating time, a shorter hospital stay, and a shorter convalescence, but a higher rate of prolapse and reintervention for prolapse.

Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review

BACKGROUND

Nodal staging in patients with rectal cancer predicts prognosis and directs therapy. Published data on the accuracy of endoscopic ultrasound (EUS) for diagnosing nodal invasion in patients with rectal cancer has been inconsistent.

AIM

To evaluate the accuracy of EUS in diagnosing nodal metastasis of rectal cancers.

METHOD

Study Selection Criteria: Only EUS studies confirmed by surgical histology were selected. Data Collection and Extraction: Articles were searched in Medline, Pubmed, and CENTRAL.

STATISTICAL METHOD

Pooling was conducted by both fixed-effects model and random-effects model.

RESULTS

The initial search identified 3610 reference articles in which 352 relevant articles were selected and reviewed. Data were extracted from 35 studies (N = 2732) that met the inclusion criteria. Pooled sensitivity of EUS in diagnosing nodal involvement by rectal cancers was 73.2% (95% confidence interval [95% CI] 70.6-75.6). EUS had a pooled specificity of 75.8% (95% CI 73.5-78.0). The positive likelihood ratio of EUS was 2.84 (95% CI 2.16-3.72), and negative likelihood ratio was 0.42 (95% CI 0.33-0.52). All the pooled estimates, calculated by fixed- and random-effect models, were similar. SROC curves showed an area under the curve of 0.79. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >.10.

CONCLUSIONS

EUS is an important and accurate diagnostic tool for evaluating nodal metastasis of rectal cancers. This meta-analysis shows that the sensitivity and specificity of EUS is moderate. Further refinement in EUS technologies and diagnostic criteria are needed to improve the diagnostic accuracy.

Isolated splenic metastases of colorectal carcinoma--case report and review of literature

It is very rare situation when surgeon can virtually expect a curative operation after revealing distal metastases of colorectal carcinoma. In case of isolated splenic metastases, splenectomy can result with good five year survival rate. There are no more than 15 cases of isolated splenic metastases publish in English speaking literature. This article reveals our case along with a literature review and brief discussion of diagnostic and therapeutic options.

In vivo magnetic resonance imaging of injected mesenchymal stem cells in rat myocardial infarction; simultaneous cell tracking and left ventricular function measurement

To determine whether magnetic resonance imaging (MRI) can enable magnetically labeled mesenchymal stem cell (MSC) tracking and simultaneous in vivo functional data acquisition in rat models of myocardial infarction. Superparamagnetic iron oxide-laden human MSCs were injected into rat myocardium infarcted by cryoinjury 3 weeks after myocardial infarction. The control group received cell-free media injection. Before injection and for 3 months after, in vivo serial MRI was performed. Electrocardiography-gated gradient echo sequence MRI and cine MRI were performed for in vivo cell tracking and assessing cardiac function using left ventricular ejection fraction (LVEF), respectively. MRI revealed a persistent signal-void representing iron-laden MSCs until ten post-injection weeks. Serial follow-up MRI revealed that LVEF was significantly higher in the MSC injection group than in the control group. We conclude that MRI enables in vivo tracking of injected cells and evaluation of the long-term therapeutic potential of MSCs for myocardial infarction.

Bronchogenic cysts of the lung: report of 29 cases

BACKGROUND

Intrapulmonary bronchogenic cysts are congenital anomalies of the tracheobronchial tree and foregut. The aim of this retrospective study was to review the diagnosis, clinical and histological features, operative techniques, outcomes and follow-up of intrapulmonary bronchogenic cysts treated in a single institute.

METHODS

Twenty-nine patients with intrapulmonary bronchogenic cysts were treated surgically between 1990 and 2005. There were 17 female and 12 male patients and their ages ranged from 7 to 68 years. Patients were divided into two groups according to surgical procedure. Resection (lobectomy or wedge resection) was performed on Group I (n=18), and partial excision with de-epithelisation was performed on Group II (n=11).

RESULTS

Twenty-five patients (86.2%) were symptomatic. Cough and sputum were the most common symptoms. Twenty-four of the 29 BCs were simple cysts (82.7%) whereas 5 (17.3%) were complicated cysts. Postoperative hospital stay was 4.55+/-0.86 days in group I and 6.54+/-3.34 days in group II (P=0.172). Complications in Group I were pneumonia in one case and wound infection in two cases; prolonged air leakage were observed in two cases of Group II. No statistical difference was determined between the complication rates of the two groups (P=0.91). However a significant difference was determined between the complication rates of simple and complicated cysts (P=0.026). Two cases in Group II showed recurrence, whereas no recurrence occurred in Group I. (P=0.065) No postoperative mortality was observed in any of the groups.

CONCLUSIONS

All bronchogenic cysts should be treated surgically. We believe that partial excision with de-epithelisation may be an alternative to resection in symptomatic patients with limited respiratory capacity.

[Acute renal failure related to urinary retention following haemorrhoidectomy performed under general anaesthesia and bilateral pudendal nerve block: a case report]

Anorectal surgery is associated with significant postoperative pain. Pudendal nerve blocks, formerly performed by surgeons, provides effective postoperative analgesia and allow a quicker recovery, which is quite important in the current concept of fast-track postoperative care. However, even for benign surgery with a safe anaesthetic technique, serious adverse events may occur. We report a case of acute renal failure related to urinary retention. Hidden by a prior history of urination difficulties, recognition of symptoms, following haemorrhoidectomy performed with bilateral pudendal block, was late. After complete recovery, electrophysiologic investigations found hypotonic, hypocontractile bladder.Therefore, before performing haemorrhoidectomy with regional anaesthesia, prior history of urination difficulties should be searched. The risk of urinary retention due to surgery and anaesthesia may be increased, as observed in this original case report.

How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review

Published data on accuracy of endoscopic ultrasound (EUS) in differentiating T stages of rectal cancers is varied. Study selection criteria were to select only EUS studies confirmed with results of surgical pathology. Articles were searched in Medline and Pubmed. Pooling was conducted by both fixed and random effects models. Initial search identified 3,630 reference articles, of which 42 studies (N = 5,039) met the inclusion criteria and were included in this analysis. The pooled sensitivity and specificity of EUS to determine T1 stage was 87.8% [95% confidence interval (CI) 85.3-90.0%] and 98.3% (95% CI 97.8-98.7%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 80.5% (95% CI 77.9-82.9%) and 95.6% (95% CI 94.9-96.3%), respectively. To stage T3 stage, EUS had a pooled sensitivity and specificity of 96.4% (95% CI 95.4-97.2%) and 90.6% (95% CI 89.5-91.7%), respectively. In determining the T4 stage, EUS had a pooled sensitivity of 95.4% (95% CI 92.4-97.5%) and specificity of 98.3% (95% CI 97.8-98.7%). The p value for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. We conclude that, as a result of the demonstrated sensitivity and specificity, EUS should be the investigation of choice to T stage rectal cancers. The sensitivity of EUS is higher for advanced disease than for early disease. EUS should be strongly considered for T staging of rectal cancers.

Different cardiovascular potential of adult- and fetal-type mesenchymal stem cells in a rat model of heart cryoinjury

Efficacy of adult (bone marrow, BM) versus fetal (amniotic fluid, AF) mesenchymal stem cells (MSCs) to replenish damaged rat heart tissues with new cardiovascular cells has not yet been established. We investigated on the differentiation potential of these two rat MSC populations in vitro and in a model of acute necrotizing injury (ANI) induced by cryoinjury. Isolated BM-MSCs and AF-MSCs were characterized by flow cytometry and cytocentrifugation and their potential for osteogenic, adipogenic, and cardiovascular differentiation assayed in vitro using specific induction media. The left anterior ventricular wall of syngeneic Fisher 344 (n = 48) and athymic nude (rNu) rats (n = 6) was subjected to a limited, nontransmural epicardial ANI in the approximately one third of wall thickness without significant hemodynamic effects. The time window for in situ stem cell transplantation was established at day 7 postinjury. Fluorochrome (CMTMR)-labeled BM-MSCs (2 x 10(6)) or AF-MSCs (2 x 10(6)) were injected in syngeneic animals (n = 26) around the myocardial lesion via echocardiographic guidance. Reliability of CMTMR cell tracking in this context was ascertained by transplanting genetically labeled BM-MSCs or AF-MSCs, expressing the green fluorescent protein (GFP), in rNu rats with ANI. Comparison between the two methods of cell tracking 30 days after cell transplantation gave slightly different values (1420,58 +/- 129,65 cells/mm2 for CMTMR labeling and 1613.18 +/- 643.84 cells/mm2 for genetic labeling; p = NS). One day after transplantation about one half CMTMR-labeled AF-MSCs engrafted to the injured heart (778.61 +/- 156.28 cells/mm2) in comparison with BM-MSCs (1434.50 +/- 173.80 cells/mm2, p < 0.01). Conversely, 30 days after cell transplantation survived MSCs were similar: 1275.26 +/- 74.51/mm2 (AF-MSCs) versus 1420.58 +/- 129.65/mm2 for BM-MSCs (p = NS). Apparent survival gain of AF-MSCs between the two time periods was motivated by the cell proliferation rate calculated at day 30, which was lower for BM-MSCs (6.79 +/- 0.48) than AF-MSCs (10.83 +/- 3.50; p < 0.01), in the face of a similar apoptotic index (4.68 +/- 0.20 for BM-MSCs and 4.16 +/- 0.58 for AF-MSCs; p = NS). These cells were also studied for their expression of markers specific for endothelial cells (ECs), smooth muscle cells (SMCs), and cardiomyocytes (CMs) using von Willebrand factor (vWf), smooth muscle (SM) alpha-actin, and cardiac troponin T, respectively. Grafted BM-MSCs or AF-MSCs were found as single cell/small cell clusters or incorporated in the wall of microvessels. A larger number of ECs (227.27 +/- 18.91 vs. 150.36 +/- 24.08 cells/mm2, p < 0.01) and CMs (417.91 +/- 100.95 vs. 237.43 +/- 79.99 cells/mm2, p < 0.01) originated from AF-MSCs than from BM-MSCs. Almost no SMCs were seen with AF-MSCs, in comparison to BM-MSCs (98.03 +/- 40.84 cells/mm2), in concordance with lacking of arterioles, which, instead, were well expressed with BM-MSCs (71.30 +/- 55.66 blood vessels/mm2). The number of structurally organized capillaries was slightly different with the two MSCs (122.49 +/- 17.37/mm2 for AF-MSCs vs. 148.69 +/- 54.41/mm2 for BM-MSCs; p = NS). Collectively, these results suggest that, in the presence of the same postinjury microenvironment, the two MSC populations from different sources are able to activate distinct differentiation programs that potentially can bring about a myocardial-capillary or myocardial-capillary-arteriole reconstitution.

Clinical case report and literature review: metachronous colorectal splenic metastases

A 52-year-old woman with a rising carcinoembryonic antigen CEA, no clinical or radiological findings, a negative colonoscopy, and a positron emission tomography (PET) scan that revealed an isolated hypermetabolic lesion in the spleen. The patient underwent splenectomy by laparoscopic surgery. The pathological study confirmed the presence of an isolated metastasis to the spleen. This case reveals the rare occurrence of isolated splenic metastases in the context of colorectal cancer and illustrates the role of PET when a patient shows a rising CEA with negative clinicoradiological studies.

Randomized clinical trial of stapled haemorrhoidopexy performed under local perianal block versus general anaesthesia

Background

The aim was to assess the feasibility of performing stapled haemorrhoidopexy under local anaesthesia.

Methods

Fifty-eight patients with haemorrhoid prolapse were randomized to receive local or general anaesthesia. The perianal block was applied immediately peripheral to the external sphincter. Submucosal block was added after applying the purse-string suture. Patients reported average and peak pain daily for 14 days using a visual analogue scale (VAS). They also completed anal symptom questionnaires before the operation and at follow-up. The surgeon assessed the restoration of the anal anatomy 3–6 months after surgery.

Results

The anal block was sufficient in all patients. The mean accumulated VAS score for average pain was 23·1 in the general anaesthesia group and 29·4 in the local anaesthesia group (P = 0·376); mean peak pain scores were 42·1 and 47·9 respectively (P = 0·537). Mean change in symptom load was also similar between the groups, with score differences of 7·0 in the general anaesthesia group and 6·1 in the local anaesthesia group. No patient had a recurrence of prolapse.

Conclusion

Perianal local block is easy to apply with a high degree of acceptability among patients. Postoperative pain, restoration of anatomy and symptom resolution were similar to that of stapled haemorrhoidopexy performed under general anaesthesia. Registration number: ISRCTN19930199 (http://www.controlled-trials.com).

Surgery for complete rectal prolapse in adults

BACKGROUND

Complete rectal prolapse is a life-style altering disability that commonly affects older people. The range of surgical methods available to correct the underlying pelvic floor defects in complete rectal prolapse suggests that there is no agreement about the choice of the best operation.

OBJECTIVES

To determine the effects of surgery on the treatment of rectal prolapse in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 10 January 2008), the Cochrane Colorectal Cancer Group Trials Register (searched 10 January 2008), CENTRAL (Issue 1, 2008), PubMed (1 January 1950 to 10 January 2008) and EMBASE (1 January 1998 to 10 January 2008). The British Journal of Surgery (January 1995 to January 2008) and the Diseases of the Colon and Rectum (January 1995 to January 2008) were specifically hand searched. The proceedings of the Association of Coloproctology meetings held from 1999 to 2007 were perused. Reference lists of all relevant articles were searched for further trials.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of adult rectal prolapse.

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected studies from the literature searches, assessed the methodological quality of eligible trials and extracted data. The four primary outcome measures were: number of patients with recurrent rectal prolapse, number of patients with residual mucosal prolapse, and number of patients with faecal incontinence or constipation.

MAIN RESULTS

Twelve randomised controlled trials including 380 participants were identified and included in this review. One trial compared abdominal with perineal approaches to surgery, three trials compared fixation methods, three trials looked at the effects of lateral ligament division, one trial compared techniques of rectosigmoidectomy, two trials compared laparoscopic with open surgery and two trials compared resection with no resection rectopexy.The heterogeneity of the trial objectives, interventions and outcomes made analysis difficult. Many review objectives were covered by only one or two studies with small numbers of participants. With these caveats in mind there is insufficient data to say which of the abdominal and perineal approaches has a better outcome. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more post-operative constipation. Laparoscopic rectopexy was associated with fewer post-operative complications and shorter hospital stay than open rectopexy. Bowel resection during rectopexy was associated with lower rates of constipation.

AUTHORS' CONCLUSIONS

The small sample size of included trials together with their methodological weaknesses severely limit the usefulness of this review for guiding practice. It is impossible to identify or refute clinically important differences between the alternative surgical operations. Larger rigorous trials are needed to improve the evidence with which to define optimum surgical treatment for rectal prolapse: the results of one such trial are awaited.

Stapled trans-anal rectal resection (STARR) by a new dedicated device for the surgical treatment of obstructed defaecation syndrome caused by rectal intussusception and rectocele: early results of a multicenter prospective study

BACKGROUND AND AIM

Obstructed defaecation syndrome (ODS) represents a very common clinical problem. The aim of the this prospective multicenter study was to evaluate the efficacy and safety of stapler trans-anal rectal resection (STARR) performed by a new dedicated device, CCS-30 Contour Transtar, in patients with ODS caused by rectal intussusception (RI) and/or rectocele (RE).

MATERIALS AND METHODS

All the patients who underwent STARR for ODS caused by RI and/or RE at Colorectal Surgery Units of S. Stefano Hospital, Naples, Gepos Hospital, Telese, Benevento and S. Maria della Pietà Hospital, Casoria, Naples, Italy were prospectively introduced into a database. Preoperatively, all the patients underwent anorectal manometry and cinedefecography. The grade of ODS was assessed using a dedicated obstructed defaecation syndrome score (ODS-S). All the patients with a ODS-S >or=12 and RI and/or RE were enrolled. Patients were followed up clinically at 6 months.

RESULTS

Thirty patients, 28 (93.3%) women, mean age 56.6+/-12.7 years, underwent STARR, by Transtar, between February and October 2006. Preoperatively, ODS-S was 15.8+/-2.4. RI was present in 26 (89.6%) and RE (34.4+/-15.2 mm) in 27 (93.1%) patients. No major postoperative complications occurred. The length of hospital stay was 2.5+/-0.6 days. At 6-month follow-up, ODS-S was 5.0+/-2.3 (P<0.001). Successful outcome was achieved in 25 (86.2%) patients.

CONCLUSION

STARR, performed by the new dedicated device, CCS-30 Contour Transtar, seems to be an effective and safe procedure to treat ODS caused by RE and/or RI. A longer follow-up and a larger number of patients is needed to confirm these results.

Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients

PURPOSE

Haemorrhoid prolapse is an indication for surgery. A correlation between worsening anatomy and increasing symptoms is commonly assumed. We developed a classification algorithm of prolapse and external component, and evaluated its correlation to symptoms before and after surgery.

METHOD

A study population comprising 180 patients operated for haemorrhoids in a multicentre randomized trial plus a validation set comprising 90 patients operated by us. The classification used three items: (i) patient self-report of prolapse requiring manual reposition; (ii) surgeon assessment of prolapse when patient negated manual reposition; (iii) surgeon assessment of external component. Patient self-reported were rated by frequency (never, 0 points; monthly, 1 point; weekly, 2 points and daily, 3 points). The algorithm yielded three grades: 1, no prolapse; 2, spontaneously reducing prolapse and 3, prolapse needing manual repositioning. The degree of external component was affixed as A, none; B, one or few tags and C, circumferential.

RESULTS

Anatomical grades did not differ between the two sets of patients before or after surgery. Preoperatively, 69% had grade 3 prolapse. Postoperatively, 89% were classified as grades 1A or B. The symptom load was similar for grades 2 and 3; mean 6.5 points preoperatively and 1.8 points postoperatively.

CONCLUSION

This anatomical classification, based on strict criteria, reliably staged the haemorrhoid prolapse. There was no unique preoperative symptom profile associated with any degree of prolapse with or without an external component. Restored anal anatomy relieved symptoms. The classification also defined recurrence of haemorrhoids.

Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele

Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.

Clinical biomarkers of angiogenesis inhibition

INTRODUCTION

An expanding understanding of the importance of angiogenesis in oncology and the development of numerous angiogenesis inhibitors are driving the search for biomarkers of angiogenesis. We review currently available candidate biomarkers and surrogate markers of anti-angiogenic agent effect.

DISCUSSION

A number of invasive, minimally invasive, and non-invasive tools are described with their potential benefits and limitations. Diverse markers can evaluate tumor tissue or biological fluids, or specialized imaging modalities.

CONCLUSIONS

The inclusion of these markers into clinical trials may provide insight into appropriate dosing for desired biological effects, appropriate timing of additional therapy, prediction of individual response to an agent, insight into the interaction of chemotherapy and radiation following exposure to these agents, and perhaps most importantly, a better understanding of the complex nature of angiogenesis in human tumors. While many markers have potential for clinical use, it is not yet clear which marker or combination of markers will prove most useful.

Isolated splenic metastasis from colon cancer. Report of a case

Isolated splenic metastasis is an uncommon event, except in the case of secondary involvement by lymphoma. The most common sites of metastases of colorectal cancer are the regional lymph nodes, liver and peritoneum; lung and bone are rarely involved, the spleen exceptionally. In this paper we report a case of metachronous isolated splenic metastasis of transverse colon cancer in an 80-year-old woman who was successfully treated by splenectomy. The peculiar clinical-pathological aspects of this kind of metastasis are discussed on the basis of our clinical observation and a review is presented of similar cases reported in the literature. Only 14 reported cases of isolated splenic metastasis from colorectal cancer were found in Medline.

Engineered cardiac organoid chambers: toward a functional biological model ventricle

A growing area in the field of tissue engineering is the development of tissue equivalents as model systems for in vitro experimentation and high-throughput screening applications. Although a variety of strategies have been developed to enhance the structure and function of engineered cardiac tissues, an inherent limitation with traditional myocardial patches is that they do not permit evaluation of the fundamental relationships between pressure and volume that characterize global contractile function of the heart. Therefore, in the following study we introduce fully biological, living engineered cardiac organoids, or simplified heart chambers, that beat spontaneously, develop pressure, eject fluid, contain residual stress, exhibit a functional Frank-Starling mechanism, and generate positive stroke work. We also demonstrate regional variations in pump function following local cryoinjury, yielding a novel engineered tissue model of myocardial infarction. With the unique ability to directly evaluate relevant pressure-volume characteristics and regulate wall stress, this organoid chamber culture system provides a flexible platform for developing a controllable biomimetic cardiac niche environment that can be adapted for a variety of high-throughput and long-term investigations of cardiac pump function.

Impact of biopsy on the accuracy of endorectal ultrasound staging of rectal tumors

PURPOSE

Endorectal ultrasound is a well-established method for the preoperative staging of rectal tumors. This prospective study was performed to establish whether obtaining a biopsy before endorectal ultrasound has an influence on staging accuracy.

METHODS

Between 1990 and 2003, a total of 333 rectal tumors were examined preoperatively by using endorectal ultrasound. All patients underwent rectal resection, and the specimens were sent for histologic evaluation. Thirty-three were not biopsied, the remaining at various times before endorectal ultrasound. The chi-squared test or Fisher's exact test were used for statistical analysis to compare the accuracies.

RESULTS

The overall staging accuracy was 71 percent but differed significantly (P = 0.004) between the groups as a function of time elapsed since biopsy. The best results were seen in tumors that were not biopsied before endorectal ultrasound, which were correctly staged in 85 percent of the cases. The least accurate staging (53 percent) was noted when endorectal ultrasound was performed in the third week after biopsy, mostly as a result of overstaging. Biopsy did not have a significant effect on nodal staging.

CONCLUSIONS

Biopsy before endorectal ultrasound significantly affects its accuracy. To achieve the most accurate staging, biopsy should be performed after endorectal ultrasound. Endorectal ultrasound staging performed in the first week after biopsy is the second best option but should be interpreted with caution in the second or third week.

Long-term outcome of stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids

PURPOSE

This study was designed to assess the long-term results of stapled hemorrhoidopexy in 291 patients with Grade III and Grade IV hemorrhoids after a minimum follow-up of five years.

METHODS

Records of patients submitted to stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids between January 1999 and December 2002 were retrospectively analyzed. Long-term outcome was evaluated with a standardized questionnaire and an office visit, including anorectal examination and rigid proctoscopy.

RESULTS

A total of 291 patients with Grade III (57.4 percent) and Grade IV (42.6 percent) hemorrhoids were evaluated. Intraoperative (20.3 percent) and postoperative (4.8 percent) bleeding was the most frequent complication. The questionnaire was submitted to all patients at a median follow-up of 73 (range 60-93) months. There were no symptoms related to hemorrhoids in 65.3 percent of patients, moderate symptoms in 25.4 percent of patients, and severe symptoms in 9.3 percent of patients. Fifty-three (18.2 percent) patients had recurrence. Reoperation was necessary in 21 (7.2 percent) patients (4 in Grade III hemorrhoids and 17 in Grade IV hemorrhoids; P < 0.001), with no recurrent symptoms and/or prolapse. Patient satisfaction for operation was 89.7 percent.

CONCLUSIONS

Stapled hemorrhoidopexy is a safe and effective treatment for Grade III and Grade IV hemorrhoids. Recurrence requiring reoperation was higher in Grade IV hemorrhoids than in Grade III hemorrhoids.

Warthin adenocarcinoma: analysis of 2 cases of a distinct salivary neoplasm

Carcinomas arising in or from the epithelial component of preexisting parotid Warthin tumors (WTs) are rare; the other histologic types of carcinoma found to arise from WTs are adenocarcinoma not otherwise specified, undifferentiated, mucoepidermoid, squamous cell, and oncocytic. The aim of this study is to describe the clinicopathologic features of a distinct salivary gland neoplasm, previously undescribed, with a striated duct phenotype arising from WT. We have designated this neoplasm "Warthin adenocarcinoma" (WA). In this retrospective study, we searched the surgical pathology files of the Department of Pathology at The University of Texas M.D. Anderson Cancer Center for cases of malignant WT and salivary adenocarcinoma not otherwise specified diagnosed from January 1, 1985, through December 31, 2006, and evaluated patients' medical records and pathologic material. We obtained tissue sections and immunohistochemically stained them with antibodies against p63; Bcl-2; cytokeratin (CK)903, CK7, CK14, and CK18; antimitochondrial antibody (AMA); smooth muscle actin; calponin; S-100; and Ki-67. We identified 2 cases of WA; both patients were women, 44 and 60 years of age, with 4.0- and 4.5-cm tumors in the left parotid gland. Histologically, the tumors were composed of bilayered duct-like structures: The inner layer was formed by a single row of columnar oxyphilic cells expressing CK7, CK14, CK18, and AMA. The outer layer was composed of multiple layers of small round dark cells with scanty cytoplasm that expressed p63, Bcl-2, and CK903 and were focally positive for AMA and negative for myoepithelial markers. The Ki-67 proliferative indices were 20%; and 25%. A residual WT with transition to carcinoma was identified in both cases. Treatment had consisted of total parotidectomy with postoperative irradiation. Patients were free of disease 1 and 3 years after treatment. Warthin adenocarcinoma is a unique salivary gland carcinoma representing the malignant epithelial counterpart of WT. The identification of additional cases would help to better elucidate the line of differentiation of the tumor and further define its natural history.

Endorectal ultrasonography versus phased-array magnetic resonance imaging for preoperative staging of rectal cancer

AIM: To compare the diagnostic accuracy of pelvic phased-array magnetic resonance imaging (MRI) and endorectal ultrasonography (ERUS) in the preoperative staging of rectal carcinoma.

METHODS: Thirty-four patients (15 males, 19 females) with ages ranging between 29 and 75 who have biopsy proven rectal tumor underwent both MRI and ERUS examinations before surgery. All patients were evaluated to determine the diagnostic accuracy of depth of transmural tumor invasion and lymph node metastases. Imaging results were correlated with histopathological findings regarded as the gold standard and both modalities were compared in terms of predicting preoperative local staging of rectal carcinoma.

RESULTS: The pathological T stage of the tumors was: pT1 in 1 patient, pT2 in 9 patients, pT3 in 21 patients and pT4 in 3 patients. The pathological N stage of the tumors was: pN0 in 19 patients, pN1 in 9 patients and pN2 in 6 patients. The accuracy of T staging for MRI was 89.70% (27 out of 34). The sensitivity was 79.41% and the specificity was 93.14%. The accuracy of T staging for ERUS was 85.29% (24 out of 34). The sensitivity was 70.59% and the specificity was 90.20%. Detection of lymph node metastases using phased-array MRI gave an accuracy of 74.50% (21 out of 34). The sensitivity and specificity was found to be 61.76% and 80.88%, respectively. By using ERUS in the detection of lymph node metastases, an accuracy of 76.47% (18 out of 34) was obtained. The sensitivity and specificity were found to be 52.94% and 84.31%, respectively.

CONCLUSION: ERUS and phased-array MRI are complementary methods in the accurate preoperative staging of rectal cancer. In conclusion, we can state that phased-array MRI was observed to be slightly superior in determining the depth of transmural invasion (T stage) and has same value in detecting lymph node metastases (N stage) as compared to ERUS.

Circular stapled hemorrhoidopexy: experience of a single center with 445 cases

This study was designed to review the results of circular stapled hemorrhoidopexy (CSH) in the management of second-, third-, and fourth-degree hemorrhoidal disease. The medical records of 483 patients who had undergone circular stapled hemorrhoidopexy for symptomatic hemorrhoidal disease from June 2001 to September 2006 were evaluated. Data regarding complications, residual symptoms, and recurrence were collected. The study included 445 patients (283 men, 162 women) between 22 and 74 years old (median age 39 years). This constituted 92% of all patients. Concomitant lateral internal sphincterotomy, skin tags' excision, and thrombus removal were done in 106 (24.0%), 83 (18.5%), and 20 (4.5%) patients, respectively. The median operating time was 24 minutes (10-45 minutes). The median hospital stay was 40 hours (11-72 hours). Complications during the first 24 hours were fecal urgency (25%), urinary retention (8%), and rectal bleeding (1%). Pruritus ani (21%), thrombosed external hemorrhoids (4%), staple line stenosis (2%), rectal bleeding (2%), anal fissure (1%), and persistent skin tags (3%) were the symptoms seen during the long-term follow-up. The median follow-up was 23 months (6-70 months). The recurrence rate was 1%. Circular stapled hemorrhoidopexy can be safely performed with low recurrence and complication rates while offering a relatively painless postoperative period for the patient.

Potential advantages of cell administration on the inflammatory response compared to standard ACE inhibitor treatment in experimental myocardial infarction

Background

Bone Marrow (BM) progenitor cells can target the site of myocardial injury, contributing to tissue repair by neovascolarization and/or by a possible direct paracrine effect on the inflammatory cascade. Angiotensin Converting Enzyme inhibitors (ACE-I) are effective in reducing mortality and preventing left ventricular (LV) function deterioration after myocardial infarction.

Methods

We investigated the short term effects of BM mononuclear cells (BMMNCs) therapy on the pro-inflammatory cytokines (pro-CKs) and on LV remodelling and compared these effects over a standard ACE-I therapy in a rat model of myocardial cryodamage.

Forty two adult inbread Fisher-F344 rats were randomized into three groups: untreated (UT; n = 12), pharmacological therapy (ACE-I; n = 14, receiving quinapril), and cellular therapy (BMMNCs; n = 16, receiving BMMNCs infusion). Rats underwent to a standard echocardiogram in the acute setting and 14 days after the damage, before the sacrifice. Pro-CKs analysis (interleukin (IL)1β, IL-6, tumor necrosis factor (TNF)α was performed (multiplex proteome arrays) on blood samples obtained by direct aorta puncture before the sacrifice; a control group of 6 rats was considered as reference.

Results

Concerning the extension of the infarcted area as well as the LV dimensions, no differences were observed among the animal groups; treated rats had lower left atrial diameters and higher indexes of LV function. Pro-Cks were increased in infarcted-UT rats if compared with controls, and significantly reduced by BMMNCs and ACE-I ; TNFα inversely correlated with LV fractional shortening.

Conclusion

After myocardial infarction, both BMMNCs and ACE-I reduce the pattern of pro-Ck response, probably contributing to prevent the deterioration of LV function observed in UT rats.

Clinicopathologic demonstration of complex bronchopulmonary foregut malformation

Bronchopulmonary foregut malformations are rare and often prove to be extremely difficult to diagnose. The presented case is a 44-year-old man complaining about cough and hemoptysis. These symptoms continued despite medical treatment. A computed thorax tomographic scan depicted a paravertebral cystic lesion. The patient underwent surgical exploration, and communication between the cyst and the esophagus was found. A left lower lobectomy was performed. The pathologic result confirmed a duplication cyst of mixed bronchogenic and esophageal type with bronchiectasis of the lower lobe. We present this unusual malformation complex especially in an adult with the review of the literature.

Stapled transanal rectal resection for outlet obstruction syndrome: results and follow-up

BACKGROUND

The objective of the present study was to assess safety, effectiveness, and long-term outcomes of stapled transanal rectal resection (STARR) for the cure of outlet obstruction syndrome (OOS).

METHODS

Data were collected over a 3-year period (2004-2007), at the Department of Surgery of the University of Genoa, from 25 consecutive subjects (19 of them females) undergoing STARR because of OOS that had not responded to medical treatment,.

RESULTS

Preoperatively, patients were submitted to clinical examination, defecography, colonoscopy, manometry, and recto-anal reflexes determination. All patients had mucosal prolapse, 15 rectal intussusception, 15 rectocele. Postoperatively no deaths were observed; one patient had a hemorrhage requiring reintervention. Mean time to resumption of normal activity was 8.5 +/- 4.5 days. Patients were followed for a mean of 24.7 +/- 10.9 months (range: 6-42 months). Late specific complications included 3 cases of urge to defecate, 8 of incontinence to flatus. Functional outcome was positive for 22 patients (excellent in 4 cases, good in 15, fairly good in 3). Six months postoperatively (25 s), patients had improvement of the mean Constipation Score (p = 0.0002), less pain during evacuation (p = 0.0003), and reduced use of digital assistance to defecate (p < 0.0001). Continence Grading Scale and enema use remained stable after intervention. Patients had increase in basal sphincter pressure (p = 0.0078) and maximal squeeze pressure (p = 0.0051). Recto-anal reflex study showed increase in abdominal pain threshold (p < 0.0001); anal sphincter relaxation threshold and desire to defecate threshold did not change.

CONCLUSIONS

According to the present study, STARR seemed to be a safe and effective treatment for OOS associated with symptomatic rectocele and intussusception.

Stapled anopexy: postoperative course and functional outcome in 400 patients

PURPOSE

We performed a retrospective analysis of postoperative course and functional outcome after at least six months' follow-up in a series of 400 consecutive patients who underwent stapled anopexy.

METHODS

All patients were evaluated at one week and one month after surgery and then according to symptoms. A clinical or telephone follow-up was obtained for all patients. The last 50 patients were prospectively evaluated with an obstructive defecation syndrome score and Wexner continence and constipation score before operation and six months after anopexy.

RESULTS

There were no intraoperative complications. Postoperative bleeding that requires reoperation was observed in 11 patients, most cases (9/11) occurring in the early experience (first 50 patients). After a median follow-up of 6.1 years, four patients required reoperation. After anopexy, we observed an improvement in patients who present disturbance in defecation. The difference between the median obstructive defecation syndrome score before and after operation was statistically significant. Wexner score showed improvement without significant difference.

CONCLUSIONS

Treatment of hemorrhoids with circular stapler seems to be effective with low morbidity and high satisfaction rate because of reduced postoperative pain and rapid recovery. This technique also allows improvement of obstructive defecation symptoms, which are seldom studied in patients with hemorrhoids.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Thoracoscopic stapled resection of multiple esophageal duplication cysts with different pathological findings

Esophageal duplication cyst is a rare congenital esophageal anomaly of the foregut. This cyst usually occurs in isolation, and thus far, was treated by enucleation through thoracoscopic or thoracotomic surgery. Here we report a case of multiple esophageal duplication cysts that showed different pathological findings, i.e., the cysts were lined with pseudostratified ciliated columnar and stratified squamous epithelium. Esophageal cysts were incidentally detected in a 53-year-old man during the treatment of pneumonia. In chest-computed tomography, the cysts showed a thin wall and homogeneous inner density, while in endoscopy, no communication with esophageal mucosa was observed. We resected the esophageal cysts with endo-staplers under thoracoscopic surgery. No postoperative complications, including esophageal mucosal injury, occurred. A follow-up chest computed tomography revealed the complete resection of the cysts.