Transanal haemorrhoidal dearterialization (THD) for selected fourth-degree haemorrhoids

Background  

Traditional treatment of fourth-degree haemorrhoidal disease (HD) is conventional haemorrhoidectomy and is frequently associated with significant pain and morbidity. In recent years, the use of transanal haemorrhoidal dearterialization (THD) for the treatment of HD has increased. The procedure aims to decrease the arterial blood flow to the haemorrhoids. Moreover, since a rectal mucopexy to treat the prolapsing component has become part of the THD technique, this treatment is also indicated for more advanced HD. The aim of this study was to assess the possible role of THD in the treatment of fourth-degree HD.     

Giant bladder diverticulum

We present the case of a 73-year-old man affected by progressive and painful abdominal distension and paresthesia/hypoesthesia at the left leg. US and CT-scan revealed the presence in the left retroperitoneum of a large cystic mass without parietal thickening or enhancement after contrast injection. This mass disappeared after positioning a vesical Foley's catheter and a retrograde cystography confirmed the suspected diagnosis of a large bladder diverticulum due to a severe prostatic hypertrophy; the patient underwent an open diverticulectomy and endoscopic prostatic resection. Bladder diverticula can occasionally appear as complex pelvic masses not obviously connected to the bladder, eventually leading to diagnostic confusion; while small size diverticulum resolves with relief of bladder outlet obstruction, open or laparoscopic diverticulectomy is needed in large size diverticulum if symptomatic, even considering the possible tumor harboring.     

History of endoscopic skull base surgery: its evolution and current reality

The history of the endoscope exemplifies the manner in which technological advances influence medicine and surgery. Endoscopic systems have evolved and improved, and they currently provide detailed visualization of a variety of deep organ structures. Otorhinolaryngological surgeons have used the endoscope for more than 30 years. In the 1990s, a number of influential neurosurgeons and otorhinolaryngological surgeons began performing purely endoscopic pituitary surgery. Endoscopic transsphenoidal operations are now extending beyond the sella. The collaboration between otorhinolaryngologists and neurosurgeons has produced a new subspecialty of "endoscopic skull base surgery." There is a great deal of progress still to be made in developing skills, instruments, and improving skull base repair. The extended skull base approaches allow surgical exposures from the olfactory groove to C-2 and to the infratemporal region and jugular fossa laterally. This article discusses the history of the endoscope, the pivotal technological advances, and the key figures in the burgeoning field of endoneurosurgery.     

Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial？

AIM To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP) and to determine the effectiveness of using a stapled and a sutured closed of pancreatic stump.METHODS Sixty-four patients underwent DP during a 10-year period. Information regarding diagnosis,operative details, and perioperative morbidity or mortality was collected. Eight risk factors were examined.RESULTS Indications for DP included primary pancreatic disease (n = 38, 59%) and non-pancreatic malignancy (n = 26, 41%). Postoperative mortality and morbidity rates were 1.5% and 37% respectively; one patient died due to sepsis and two patients required a reoperation due to postoperative bleeding. Pancreatic fistula was developed in 14 patients (22%); 4 of fistulas were classified as Grade A, 9 as Grade B and only 1 as Grade C. Incidence of pancreatic fistula rate was significantly associated with four risk factors pathology,use of prophylactic octreotide therapy, concomitant splenectomy, and texture of pancreatic parenchyma.The role that technique (either stapler or suture) of pancreatic stump closure plays in the development of pancreatic leak remains unclear.CONCLUSION The pancreatic fistula rate after DP is 22%. This is reduced for patients with non-pancreatic malignancy, fibrotic pancreatic tissue, postoperative prophylactic octreotide therapy and concomitant splenectomy.     

Intracranial melanocytic meningeal tumours and melanosis oculi: case report and literature review

ABSTRACT: BACKGROUND: Melanocytic meningeal tumours are rare extra-axial neoplasms of the nervous system, with only three reported cases in the cavernous sinus. Herein we describe for the first time the association of ocular melanosis and multiple intracranial melanocytic meningeal tumours, with the presenting lesion being in the cavernous sinus. The importance of this association is discussed together with the diagnostic and therapeutic challenges of the case. CASE PRESENTATION: A 20-year-old man presented with a left sixth cranial nerve deficit; general examination documented only congenital melanosis of the homolateral eye. MRI examination showed a space occupying lesion in the left cavernous sinus, which was followed conservatively for 2 years, until a new space occupying lesion was evident at the level of the right frontal convexity: both lesions presented with neuroradiological characteristics suggestive of melanin content. The frontal convexity lesion was removed: intraoperatively the dura was markedly and diffusely melanotic. Histological examination documented a melanocytic meningeal tumour, with a proliferative index of 3%. The patient underwent 3D-Conformal Radiation Therapy on the lesion of the cavernous sinus (total dose 5040 cGy), with initial tumour reduction. Three years later, due to a symptomatic growth, he underwent partial removal of the lesion in the cavernous sinus. Histological examination was unchanged. He then received adjuvant Temozolomide with Low Dose Fractionated Radiation Therapy (LD-FRT). Due to further disease progression cisplatin plus fotemustine were administered, concomitant with LD-FRT: after two cycles MRI documented significant disease regression. After a period of apparent disease control, the patient presented with persistent cough and evidence of multiple thoracic metastases, which lead to his death, seven years after presentation. CONCLUSIONS: Intracranial melanocytic meningeal tumours are challenging lesions, both from a diagnostic and therapeutic point of view; though rare, the possible association with ocular melanosis should be recognized and might facilitate an early diagnosis. Surgery remains the best possible option when feasible. In the event of partial resection, this "benign" disease might be clinically aggressive.