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Recurrent hemorrhoidal disease after stapled prolassectomy: hypothesis on predictive factors and surgical management
Full text linkINTRODUCTION
The surgical procedure of stapled haemorrhoidopexy is now considered safe and its safety is improving with experience and technical upgrading. Compared to conventional procedures, stapled haemorrhoidopexy has the advantage - in the short term results - of less postoperative pain but the main disadvantage - in the long term follow-up- of possible recurrent prolapse.
This occurs between three months and one year after the operation and should be differentiated -for a more correct evaluation of the results- by the persistent prolapse, that is immediately evident after surgery or in the first two months. Both –persistent and recurrent prolapse- required treatment if symptomatic.
The percentage of symptomatic prolapse -persistent and recurrent- after stapled procedures varies widely in the several clinical trials described in the literature, ranging from a minimum of 2% to the worst results of 53.3% (1-9). The unsatisfactory results mainly depend on incorrect indications (IV grade haemorrhoids with predominant external, fibrous component), technical mistakes during surgical procedure and insufficient prolapse correction.
Avoiding or minimizing the possibility of a recurrent prolapse should be demanded to a well realized primary operation, calibrated on the effective amount of the prolapse (using single or double stapled technique, instruments with larger case, parachute technique, or with an immediate, intraoperative correction of the persistent prolapse or excision of a residual pile).
The aim of this work is to analyze the different features of recurrences after stapled haemorrhoidal operations and the procedures realized to treat them in order to lay down solid and firm starting points to focalize some guidelines of treatment of recurrences after stapled prolapsectomy
MATERIAL AND METHODS
We performed a retrospective study on 69 patients, affected by recurrent or residual prolapse after a primary operation of stapled haemorrhoidopexy (58 patients treated with a single PPH -PPH- and 11 with a double stapling procedure -DSPPH-) and undergoing reoperative surgery for the treatment of recurrence (Table I). This cohort of patients was recruited between January 2005 and January 2011 in three Italian national reference centers for proctological surgery (Pisa, Rome and Pordenone) and was retrospectively analyzed.
RESULTS
The symptoms of primary onset had been: haemorrhoidal crisis in 17 patients, bleeding in 5 patients, prolapse in 45 patients and finally both prolapse and bleeding in 2 patients. (Table 2)
58 out of 69 patients had undergone a PPH at the primary operation and 11 out of 69 a DSPPH.
In 23 patients (34%) primary surgery had been performed in other Hospitals.
Prolapse degree according to Goligher’s classification was: II degree in 15 cases, III degree in 36 cases, IV degree in 18 cases (Table 3).
The mean time of recurrence was 18 months (range 2-42 months) in the 58 patients, who had undergone a PPH and 12 months (range 2-42 months) in those who had undergone a D-PPH (Table 4).
All operations were performed at least six months after the onset of the recurrence’s symptoms. Only two patients underwent a reoperation after about two months for a haemorrhoidal thrombosis.
The clinical onset of recurrence appeared in the form of: haemorrhoidal crisis in 12 patients, bleeding in 8 patients, recurrent prolapse in 29 patients and residual prolapse in 20 patients (Table 5).
Intraoperative findings in the 58 patients, who had undergone a previous single PPH, were: 30 recurrent or residual prolapsed haemorrhoids with single or multiple piles- ≤3- (17 residual and 13 recurrent), 4 congested haemorrhoids, 18 mobile prolapse, 6 mobile prolapse associated with thrombosed haemorrhoids.
In these cases the operations chosen were: 34 excisional surgery, 12 PPH, 6 DSPPH, 6 PPH plus excisional surgery.
Intraoperative findings in the 11 patients, who had undergone a previous DSPPH, were: 6 recurrent or residual prolapsed haemorrhoids with single or multiple piles- ≤3- (3 residual and 3 recurrent), 2 congested haemorrhoids, 2 mobile prolapse, 1 mobile prolapse associated with thrombosed haemorrhoids.
In these cases the operations chosen were: 8 excisional surgery, 1 PPH, 1 DSPPH, 1 PPH plus excisional surgery.
Table 6 and 7 describe the intraoperative reports after a previous PPH and after a previous DSPPH and the operations applied.
The preoperative and postoperative management (use of painkillers drugs, antibiotics and laxatives), the kind of anaesthesia -general or local- of the patients undergoing reoperative surgery for recurring haemorrhoids was similar to that applied in the first operation.
The mean operative time was comparable to that of the primary surgery in patients treated with PPH or DSPPH or excisional surgery.
The hospital stay and return to full activity were similar to the primary operations.
Postoperative complications after a “stapled” operation (PPH, DSPPH) and after a “non stapled”operation are summarised in Table 8. They were comparable to those relative to primary surgery.
In the “stapled” group bleeding occurred in 3 patients.
In one case the bleeding was controlled by introducing a Foley catheter into the anorectum and by inflating its balloon at 30-40 cm3, one case was coped with a local application of a hemostatic device, one case required a surgical revision under anaesthesia.
In the “non stapled” group, instead, bleeding occurred in 1 patient and required a surgical revision.
2 patients in the “stapled” group and 2 patients in the “non stapler” group complained of urgency but this symptoms solved spontaneously one month after operation.
Postoperative pain was under control in both group thanks to the use of the routine FANS usually employed. However, there were 2 patients in the “stapled” group and 2 patients in the “non stapler” group, who reported persisting anal pain in the 2 weeks following operation and required further use of painkillers. After this time, the pain symptoms disappeared in these three patients and continued in the other one.
The mean follow-up after reoperative surgery resulted in 40 months (range, 23-96)
No cases of second recurrence occurred in the treated patients.
The outcome assessed on the basis of the clinical examination, as well as at the opinion expressed by the patients was excellent in 34 patients, good in 23 patients, sufficient in 8 patients, poor in 4 patients because two considered their symptoms (bleeding and congested haemorrhoids) unchanged, one reported a worsening of constipation and another complained of persistent pain.
DISCUSSION
The presence of a residual or recurrent prolapse can be derived or from an incorrect indication to surgery or from an insufficient resective approach. Alternatively it may be due to an operation, which had been previously carried out incorrectly with an insufficient pull of the prolapsed tissue in the operative case.
In case of recurrence, symptoms guide to the decision of a reoperation and the surgical technique is determined according to the intraoperative report, that in almost equal percentage is divided between the mobility of the prolapse and the presence of recurrent and/or residual haemorrhoidal prolapsed piles.
In the case of a mobile prolapse the choice was a transrectal resection with stapler (PPH or DSPPH, depending on the amount of the prolapse that should be resected). On the contrary, in the case of a fixed prolapse or single or multiple piles -≤3_, the choice should be a traditional surgery (Milligan Morgan, whatever performed). In case of multiple piles ≥3 the choice is a transrectal resection with stapler (PPH or DSPPH, depending on the amount of the prolapse that should be resected). A PPH combined with Milligan Morgan Haemorrhoidectomy is applied in case of a mobile prolapse with some residual pile.
CONCLUSIONS
Avoiding or minimizing the possibility of a recurrent prolapse should be demanded to a well realized primary operation, calibrated on the effective amount of the prolapse.
A complete clinical study with a correct evaluation of the symptoms and a careful intraoperative assessment of the recurrence’s features are of primary importance for the choice of the technique to be applied.
Re-excisional surgery but also a re-stapled procedure can be safely and successfully realized with the same operating methods of a primary operation, with no more complications or difficulties
Hypothermic Machine Perfusion and Spontaneous Kidney Allograft Rupture: Causation or Correlation? A Case Report and Review of Pertinent Literature
No full textBackground. Spontaneous kidney allograft rupture (KAR) is a severe complication of kidney transplant. KAR occurs when no identifiable injuries noted at the time of the organ retrieval are present. KAR is associated with acute rejection, renal vein thrombosis, severe acute tubular necrosis, or trauma. In recent years, the introduction of hypothermic machine perfusion (HMP) has provided an excellent option for kidney allograft preservation reducing the incidence of delayed graft function. On the other hand, HMP can also represent a potentially traumatic event for a fragile graft, especially one belonging to expanded criteria donor.Case Presentation. Here, to our knowledge, we report the first case of KAR after the use of HMP, which occurred in 60-year-old women undergoing a single kidney transplant from a dona-tion after brain death donor belonging to the expanded criteria donor category. The allograft was perfused for 240 minutes with HMP with passive oxygenation. The post-transplant course was unremarkable with early graft function, but on post operatory day 14 the patient complained of severe pain over the transplant site. A computed tomography scan showed a massive fluid collec-tion in the perigraft region. Immediate surgical exploration showed 2 lacerations of 10 cm and 5 cm length at the upper and midpole of the kidney, requiring transplantectomy. Histologically, the graft did not show features of acute rejection.Conclusions. In the presented case, the repair and salvage of the kidney allograft was not possible. However, the review of the pertinent literature does not report another case linking HMP to KAR
Cancer stem cells as functional biomarkers
No full textAccording to the American Association of Cancer Research (AACR), a Cancer Stem Cell is a cell within a tumor that possesses the capacity to self-renew and to cause the heterogeneous lineages of cancer cells that constitutes the tumor [1]. Cancer Stem Cells (CSCs) are involved in the metastatic process, in the resistance to therapeutic treatments of many types of human cancers and consequently in the onset of recurrences. Numerous translational studies have been conducted to understand CSC characteristics and evaluate association between CSC-related biomarkers and clinical outcomes. The CSC theory can explain also a tumor relapse after that a tumor has been completely surgically removed (R0 macroscopical zero residual resection) or after an apparently complete response to chemoteraphy. CSCs, in fact, showed a marked ability to reduce intracellular accumulation of chemotherapic agents by active drug extrusion, increased chemoresistance and survival, as well as elevated membrane transporter activity. In addition, it is possible that these cancer stem cells may nest in the "secured" (niche) sites of our body, where they may remain undisturbed for a long time, even years, until a stimulus arrives to awaken them, causing the disease to resume. CSCs, in fact, are able to use a variety of cellular pathways to survive to anticancer treatments. More recently CSCs have been described in several solid tumors, expressing specific biomarkers. Another field of research should be focused on the realization of diagnostic instruments to follow up patients after R0 surgical resection or after a complete response for an early detection and management of relapse and metastasis
Long-term Survival After Nephron-Sparing Surgery for Kidney Allograft Tumors: Case Reports from a Single Transplant Center
No full textStandard stapled transanal rectal resection vs stapled transanal rectal resection with only one high volume stapler in the prevention of complications in old patient: our experience
Full text linkBACKGROUND: The causes of obstructed defecation syndrome (ODS) can actually be either functional or mechanical (primary or secondary deficit of the sensitivity, slow bowel transit, pelvic floor dyssynergia, internal and external rectal prolapse, recto-anal intussusceptions, anterior or posterior rectocele and pelvic prolapse of the bladder, uterus, bowel or sigma). The aim of our study was evaluate the safety, efficacy and feasibility of Transanal Rectal Resection (STARR) procedure performed by a single or double stapler through clinical and functional outcomes for transanal stapled surgery. METHODS: From January 2016 to October 2017, ninety patients with ODS secondary to rectal prolapse, anal-rectal intussusception and anterior rectocele, that underwent to a STARR procedures were enrolled. Thirty of these underwent a STARR procedure with double circular stapler PPH-01 (Group A); 30 with single circular stapler CPH34HV with a purse string suture (Group B); and 30 with single circular stapler CPH34HV with a "parachute technique" (Group C). All patients were selected with clinical examination, Wexner score for fecal incontinence and ODS score for constipation. Patients also underwent a Defeco RMN for an anatomical and dynamic evaluation of the pelvic floor. RESULTS: No recurrence rates were observed in the three groups. The mean operative time was 46,3 minutes in group A; 34,5 minutes in group B; and 37,6 minutes in Group C. The volume of the resected specimen was 17 ml in group A; 15 ml in group B; and 16 ml in Group C. Complications were bleeding (3.3% in group A); fecal urgency (6.6% in group A, 10% in group B and 3.3% in group C); rectal hematoma (3.3% in group A). All symptoms significantly improved after the operation without differences between groups. CONCLUSIONS: The STARR technique performed with a single stapler CPH34HV is safe, faster and less expensive than the STARR performed by a double PPH01. Besidas, with the parachute technique, it is possible to resect asymmetric prolapses
Use of the circular compression stapler and circular mechanical stapler in the end-to-side transanal colorectal anastomosis after left colon and rectal resections A single center experience
No full textThe aim of our study was to compare the efficacy of the circular compression stapler and the circular mechanical stapler in transanal colorectal anastomosis after left colectomy or anterior rectal resection.
We performed a retrospective analysis of 10 patients with disease of the, sigmoid colon or rectum (carcinoma or diverticular disease) who underwent left colectomy or anterior rectal resection with end-to-side transanal colorectal anastomosis. A follow-up was planned for all patients at 1, 3 and 6 months after surgery and the anastomosis was evaluated by colonoscopy at 1 year.
In all patients an end-to-side transanal colorectal anastomosis was performed using a circular compression stapler (CCS group) or circular mechanical staplers with titanium staples (CMS group). The mean distance of the anastomosis from the anal margin was 6.4 ± 1.5 cm in the CCS group and 18.2 ± 11.2 cm in the CMS group. All patients in the CCS group expelled the ring after a mean time of 8.2 postoperative days. At 12 months colonoscopy revealed that all CCS patients had a satisfactory anastomosis with mean size of the colic lumen at the level of anastomotic line of 26.3 mm.
In our experience the circular compression stapler a valuable alternative to the circular mechanical stapler for the creation of transanal colorectal anastomosis, in line with the relevant literature
Laparoscopic diagnosis and treatment of diaphragmatic Morgagni hernie. Case report and review of the literature
No full textBACKGROUND: Morgagni's hernia is a rare and congenital type of diaphragmatic hernia. The majority of these are asymptomatic and diagnosed incidentally during evaluation or treatment for other conditions. When diagnosis is made surgery is mandatory. The Authors report the laparoscopic repair of small Morgagni hernia, followed by review of the literature. MATERIALS AND METHODS: A case of 55-year-old woman complaining a sensation of tightness in her chest, but especially an oppressive epigastric pain with episodes of fainting fit and breathless is described. The definitive diagnosis was confirmed by laparoscopy. The hernia was repaired laparoscopically using a mesh fixed by hernia stapler after excision of the sac. RESULTS: In the postoperative patients has presented an episode of heart condition due to pericarditis treated pharmacologically. The patient was discharged on the seventh postoperative day symptom-free. CONCLUSIONS: Laparoscopic technique must be considered as a first line approach for the treatment of Morgagni hernia, easy and safe by carry out. We recommend do not excise hernia sac, even if small, and particular cure in the use of the mesh fixed by metal staples
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