Diaphragmatic rupture: A single-institution experience and literature review.

BACKGROUND: Diaphragmatic rupture (DR) is a rare and potentially life-threatening event caused by trauma or spontaneously. DR occasionally occurs several months after the injury. Chest X-ray and computed tomography are the most effective diagnostic methods. Delay in DR diagnosis occurs frequently. This study aimed to examine and improve our understanding of the etiology, clinical presentation, and management of DR. METHODS: This study was performed at the Emergency and General Surgery Department of Fondazione I.R.R.C.S. Cà Granda, Ospedale Policlinico in Milan (Italy). Patients diagnosed with DR between 2001 and 2011 who underwent surgery were included, and their data were retrospectively collected. RESULTS: Fourteen patients were diagnosed with DR, mainly left-sided DR. Road traffic collisions were the main causes (86%). DR diagnosis was preoperatively established in eight patients (57%). Chest X-ray was diagnostic in 50% of the patients and computed tomography in three patients (60%). Twelve patients had a diaphragmatic hernia. DR was repaired with a mesh in two patients. Mean hospital stay was 16.6 days. CONCLUSION: Difficulty in achieving early diagnosis of DR is due to its nonspecific presentation. High index of suspicion is needed. Its treatment is using surgery involving reduction of the viscera and repair of the diaphragm defect.

The Role of Ultrasound Elasticity Imaging in Predicting Ileal Fibrosis in Crohn's Disease Patients.

BACKGOUND: Bowel wall fibrosis is associated with a complicated disease behavior in patients with Crohn's disease (CD). The quantitative assessment of fibrosis severity in CD-affected bowel can help clinical decision making. Our aim was to evaluate the feasibility, reliability, and reproducibility of ultrasound elasticity imaging (UEI) toward the assessment of ileal fibrosis in CD patients. METHODS: Twenty-three consecutive patients with ileal or ileocolonic CD, elected for surgical resection of the terminal ileum, underwent bowel ultrasound and UEI. Twenty inflammatory CD patients without complications were enrolled as controls. Bowel wall stiffness was evaluated with UEI by means of color scale and quantitative strain ratio measurement. The severity of bowel wall fibrosis and inflammation were evaluated on histological sections by semiquantitative and quantitative image analysis and used as a reference standard. RESULTS: The UEI strain ratio measurement was significantly correlated with the severity of bowel fibrosis at both semiquantitative and quantitative histological image analysis: it was characterized by an excellent discriminatory ability for severe bowel fibrosis (area under the receiver operating characteristic curve: 0.917; 95% confidence interval, 0.788-1.000). UEI strain ratio measurements were characterized by an excellent interrater agreement. At multivariate analysis, bowel wall fibrosis proved the only independent determinant of the strain ratio. The ileal strain ratio of inflammatory CD patients was significantly lower than in operated CD patients with severe fibrosis. CONCLUSIONS: UEI can be used to assess ileal fibrosis in CD patients.

Surgery and diagnostic imaging in abdominal Crohn's disease.

Surgery is well-established option for the treatment of Crohn's disease that is refractory to medical therapy and for complications of the disease, including strictures, fistulas, abscesses, bleeding that cannot be controlled endoscopically, and neoplastic degeneration. For a condition like Crohn's disease, where medical management is the rule, other indications for surgery are considered controversial, because the therapeutic effects of surgery are limited to the resolution of complications and the rate of recurrence is high, especially at sites of the surgical anastomosis. In the authors' opinion, however, surgery should not be considered a last-resort treatment: in a variety of situations, it should be regarded as an appropriate solution for managing this disease. Based on a review of the literature and their own experience, the authors examine some of the possibilities for surgical interventions in Crohn's disease and the roles played in these cases by diagnostic imaging modalities.

Pudendal Neuralgia: A New Option for Treatment? Preliminary Results on Feasibility and Efficacy.

OBJECTIVE: The aim of this prospective study was to investigate the feasibility and report the short-term results of a new procedure for treatment of pudendal neuralgia, consisting of transperineal injections of autologous adipose tissue with stem cells along the Alcock's canal. METHODS: Fifteen women with pudendal neuralgia not responsive to 3-months medical therapy were examined clinically, with VAS score, validated SF-36 questionnaire, and pudendal nerve motor terminal latency (PNMTL). These patients were submitted to pudendal nerve lipofilling. Clinical examinations with VAS, SF36, and PNTML were scheduled during 12 months follow-up, with the incidence of pain recurrence (VAS > 5) as primary outcome measure. Appropriate tests were used for statistics. RESULTS: All patients had preoperative increase of pudendal nerve latencies. Twelve patients completed the follow-up protocol. There was no mortality, and no complications. Two patients had no pain improvement and continued to use analgesic drugs. At 12 months VAS significantly improved (3.2 ± 0.6 vs 8.1 ± 0.9, P < 0.001), as well SF36 (75.5 ± 4.1 vs 85.0 ± 4.5 preoperative, P < 0.01), while PNTML showed a nonsignificant trend to a better nerve conduction (2.64 ± 0.04 vs 2.75 ± 0.03 preoperative, P = 0.06). CONCLUSIONS: The new technique seems to be easy, with low risk of complications, and with significant improvement of symptoms in the short period. A larger study with appropriate controls and longer follow-up is now needed to assess its real effectiveness.

Pyogenic vertebral osteomyelitis complicating abdominal penetrating injury: case report and review of the literature.

Pyogenic vertebral osteomyelitis is a rare condition usually associated with endocarditis or spinal surgery. However, it may also occur following abdominal penetrating trauma with associated gastrointestinal perforation. Diagnosis might be challenging and appropriate treatment is essential to ensure a positive outcome. In trans-abdominal trauma, 48 hours of broad-spectrum antibiotics is generally recommended for prophylaxis of secondary infections. A case report of vertebral osteomyelitis complicating trans-colonic injury to the retroperitoneum is presented and clinical management is discussed in the light of literature review.

Surgical treatment of ulcerative colitis in the biologic therapy era.

Recently introduced in the treatment algorithms and guidelines for the treatment of ulcerative colitis, biological therapy is an effective treatment option for patients with an acute severe flare not responsive to conventional treatments and for patients with steroid dependent disease. The reduction in hospitalization and surgical intervention for patients affected by ulcerative colitis after the introduction of biologic treatment remains to be proven. Furthermore, these agents seem to be associated with increase in cost of treatment and risk for serious postoperative complications. Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in ulcerative colitis patients. Surgery is traditionally recommended as salvage therapy when medical management fails, and, despite advances in medical therapy, colectomy rates remain unchanged between 20% and 30%. To overcome the reported increase in postoperative complications in patients on biologic therapies, several surgical strategies have been developed to maintain long-term pouch failure rate around 10%, as previously reported. Surgical staging along with the development of minimally invasive surgery are among the most promising advances in this field.

Effects of surgery on peripheral N-terminal propeptide of type III procollagen in patients with Crohn's disease.

AIM: This study investigates the effects of surgery on collagen turnover in patients affected by Crohn's disease (CD). METHODS: Fifteen patients affected by active CD, assessed according to the Crohn's disease activity index, and confirmed by histology, with different pharmacological treatments, were enrolled in the study. N-Terminal propeptide of type III collagen was assessed on peripheral blood before and 6 months after surgery, as an index of collagen turnover. A control group of 15 healthy age- and sex-matched subjects was also studied. RESULTS: In CD patients peripheral N-terminal propeptide of type III collagen serum levels were significantly higher than in controls before surgery (5.0 +/- 1.8 vs 2.7 +/- 0.7 microg/l, respectively; p = 0.0001). Six months after these values were significantly reduced (from 5.0 +/- 1.8 to 3.1 +/- 0.8 microg/l; p = 0.003). Independently on the pretreatment regimen and the duration of the disease, an improvement in the patients' symptoms was observed. CONCLUSIONS: The surgical resection of the affected intestinal segment in CD patients seems to be able to break down the collagen synthesis processes. Peripheral N-terminal propeptide of type III collagen could be seen as an additive marker to clinical and endoscopic observations after surgery.

Elevated serum procollagen type III peptide in splanchnic and peripheral circulation of patients with inflammatory bowel disease submitted to surgery.

BACKGROUND: In the hypothesis that the increased collagen metabolism in the intestinal wall of patients affected by inflammatory bowel disease (IBD) is reflected in the systemic circulation, we aimed the study to evaluate serum level of procollagen III peptide (PIIIP) in peripheral and splanchnic circulation by a commercial radioimmunoassay of patients with different histories of disease. METHODS: Twenty-seven patients, 17 with Crohn and 10 with ulcerative colitis submitted to surgery were studied. Blood samples were obtained before surgery from a peripheral vein and during surgery from the mesenteric vein draining the affected intestinal segment. Fifteen healthy age and sex matched subjects were studied to determine normal range for peripheral PIIIP. RESULTS: In IBD patients peripheral PIIIP level was significantly higher if compared with controls (5.0 +/- 1.9 vs 2.7 +/- 0.7 microg/l; p = 0.0001); splanchnic PIIIP level was 5.5 +/- 2.6 microg/l showing a positive gradient between splanchnic and peripheral concentrations of PIIIP. No significant differences between groups nor correlations with patients' age and duration of disease were found. CONCLUSIONS: We provide evidence that the increased local collagen metabolism in active IBD is reflected also in the systemic circulation irrespective of the history of the disease, suggesting that PIIIP should be considered more appropiately as a marker of the activity phases of IBD.

Effects of chronic inflammatory bowel diseases on left ventricular structure and function: a study protocol.

BACKGROUND: Experimental evidences suggest an increased collagen deposition in inflammatory bowel diseases (IBD). In particular, large amounts of collagen type I, III and V have been described and correlated to the development of intestinal fibrotic lesions. No information has been available until now about the possible increased collagen deposition far from the main target organ. In the hypothesis that chronic inflammation and increased collagen metabolism are reflected also in the systemic circulation, we aimed this study to evaluate the effects on left ventricular wall structure by assessing splancnic and systemic collagen metabolism (procollagen III assay), deposition (ultrasonic tissue characterization), and cardiac function (echocardiography) in patients with different long standing history of IBD, before and after surgery. METHODS: Thirty patients affected by active IBD, 15 with Crohn and 15 with Ulcerative Colitis, submitted to surgery will be enrolled in the study in a double blind fashion. They will be studied before the surgical operation and 6, 12 months after surgery. A control group of 15 healthy age and gender-matched subjects will also be studied. At each interval blood samples will be collected in order to assess the collagen metabolism; a transthoracic echocardiogram will be recorded for the subsequent determination of cardiac function and collagen deposition. DISCUSSION: From this study protocol we expect additional information about the association between IBD and cardiovascular disorders; in particular to address the question if chronic inflammation, through the altered collagen metabolism, could affect left ventricular structure and function in a manner directly related to the estimated duration of the disease.