Abdominal wall incisional hernia repair improves respiratory function: results after 3 years of follow-up.

PURPOSE: Hernias severely impact patient quality of life (QoL), and 80% of patients require a surgical operation. Moreover, hernias are responsible for respiratory function alterations. This study aims to investigate the postoperative alterations in respiratory function after open ventral hernia repair in patients with incisional hernia. METHODS: Patients operated on at the Policlinico "Paolo Giaccone" at Palermo University Hospital between January 2015 and December 2016 were identified in a prospective database. Fifty-one patients were enrolled in the study. The respiratory outcome measures used were forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, peak expiratory flow (PEF) and PEF percentage (%PEF). The timepoints at which the parameters listed were assessed were t0, 1 week before the surgical operation; t1, 12 months later; and t2, 3 years later. RESULTS: The difference between mean preoperative and postoperative PEF was significant [t0 4.32 (4.03-7.92), t1 6.7 (4.27-8.24) with p = 0.012 and t2 6.5 (4.25-8.21) with p = 0.026]. The %PEF increased from 75% preoperatively to 87% at t1 (p = 0.009) and to 85% at t2 (p = 0.03). No differences were found in the comparison of pre- and postoperative FVC, FEV1 or FEV1/FVC ratio. CONCLUSION: The improvement in respiratory measures suggests the importance of abdominal wall restoration to recover functional activity of respiratory function.

VIP conditions human endometrial receptivity by privileging endoplasmic reticulum stress through ATF6α pathway.

Endometrial stromal cells undergo endoplasmic reticulum (ER) stress and unfolded protein response (UPR) during the decidualization linked with the inflammation and angiogenesis processes. Considering VIP (vasoactive intestinal peptide) induces the decidualization program, we studied whether modulates the ER/UPR pathways to condition both processes for embryo implantation. When Human Endometrial Stromal Cell line (HESC) were decidualized by VIP we observed an increased expression of ATF6α, an ER stress-sensor, and UPR markers, associated with an increase in IL-1ß production. Moreover, AEBSF (ATF6α -inhibitor pathway) prevented this effect and decreased the expansion index in the in vitro model of implantation. VIP-decidualized cells also favor angiogenesis accompanied by a strong downregulation in thrombospondin-1. Finally, ATF6α, VIP and VPAC2-receptor expression were reduced in endometrial biopsies from women with recurrent implantation failures in comparison with fertile. In conclusion, VIP privileged ATF6α-pathway associated with a sterile inflammatory response and angiogenesis that might condition endometrial receptivity.

Outpatient management of proctologic disease. Which techniques for local anesthesia? The experience of a single center.

INTRODUCTION: Since 1899 outpatient management of surgical patients had been increasing, becoming the best option when possible. In 1988 was described the first experience of outpatient management of proctologic disease. Advances in local anesthesia techniques have improved the outpatient approach to surgical disease, particularly in patients with proctological diseases. METHODS: From 2010 to 2016, 1160 patients who needed surgery for proctologic disease have been recruited: 239 hemorrhoidectomies using the variant of Milligan Morgan technique described by Phillips, 45 trans-anal hemorrhoidal DE-arterialization (THD), 315 sphincterotomies, 12 anal polypectomies, 230 loop seton positions, 65 cone-like fistulectomies and 254 fistulotomies for perianal fistulas. In 329 cases, we used the posterior perineal block, 603 local perineal blocks, and 228 tumescent anesthesia. RESULTS: On a total of 1160 procedure failure rate was of 4.7% (55 cases). Urinary retention (69% 38 cases); bleeding 18% (10 cases), uncontrolled pain 12% of cases (7 cases). The chi-square test demonstrates (p<0.01) that the failure rate of the three types of anesthesia is very different with high statistical significance. The failure rate in patient underwent Posterior Perineal Block was 27/329 cases (8.2%), 8/228 (3.5%) in patients who underwent Tumescent Anesthesia and 20/603 (3.3%) in who underwent Local Perineal Block. CONCLUSIONS: Outpatient protocols represent the most common approach to minor proctologic disease that needs a good local block, with a good analgesic and sedative assistance, the different local block seems to be the same concerning the pain control, but presents some little, not relevant difference concerning urinary retention rate.

Benign multicystic mesothelioma: a case report of recurrent disease in a young adult with familiarity for renal cell carcinoma.

Benign multi-cystic peritoneal mesothelioma (BMCM) is a very rare disease (about 150 cases observed). The aetiology is currently little-known, and the data collected, without having achieved conclusive re sults, identify two possible causes: neoplastic and reactive inflammatory. This case report refers to a recidivism of BCMC in a patient whose brother, few months before, underwent a left nephrectomy and right renal Radio Frequency Termo Ablation (RFTA) for bilateral papillary renal cell carcinoma. For the recurring trend, the onset in a male young patient without chronic inflammatory diseases evidence, the presence of a first degree relative with a rare carcinoma we supposed a neoplastic aetiology. The available literature suggests that both tumours (BCMC and renal cell carcinoma) are susceptible to oestrogens. This biomolecular mechanism could represent a valid antipathogenic hypothesis.

Use of the KSVM-based system for the definition, validation and identification of the incisional hernia recurrence risk factors.

BACKGROUND: Incisional hernia is one of the most common complications after abdominal surgery with an incidence rate of 11 to 20% post laparotomy. Many different factors can be considered as risk factors of incisional hernia recurrence. The aim of this study is to confirm and to validate the incisional hernia recurrence risk factors and to identify and to validate new ones. METHODS: In the period from July 2007 to July 2017, 154 patients were selected and subjected to incisional hernia repair. The surgical operations were conducted under general anaesthesia. Patients received antibiotic prophylaxis when indicated, according to the hospital prophylaxis scheme. Inclusion criteria of the study were single operator case studies and open laparotomy for incisional hernia repair. The statistical analysis proposed to identify and to verify the risk factors for recurrence of incisional hernia is the Support Vector Machine (SVM). The analysis was conducted verifying 34 risk factors. RESULTS: The data analysis confirmed the known correlations showed in the international literature with a greater incidence of comorbidities such as diabetes 37%, dyslipidaemia and hypercholesterolemia with a cumulative incidence of 16%; tobacco smoke - by combining categories smokers and ex-smokers - reach 46%, COPD 16% and hypertension 51%. CONCLUSIONS: The analysis of the data therefore confirmed the correlations showed in the international literature. A KSVM-based system to classify incisional hernia recurrence has been presented. The type of prosthesis and the site of its implant also play a significant role in the development of the recurrence. Sensitivity (86,25%), Specificity (87,14%), Negative Predictive Value (84,72%), Precision (88,46%), Accuracy (86,67%), and Error (13,33%) scores obtained using the proposed technique highlight the validity for the relapse's classification methodology.

Mapping the centers performing endocrine neck surgery in Italy.

BACKGROUND: Quality of care and provider's experience seem to be strictly connected in any field of surgery. Aim of this study is to identify a method to classify the centers on the basis of the number of thyroidectomies and parathyroidectomies performed. METHODS: We listed 666 centers performing endocrine neck surgery in 2015, from the database of the Italian Health Ministry. We performed a descriptive statistic analysis with a dedicated software. We identified the outliers, according to a previous literature review, in those centers performing >1000 and < 10 thyroidectomies, >100 and < 3 parathyroidectomies and we excluded them to our analysis. The remaining centers were grouped in a box-plot. Third quartile, median, procedures performed/3rd quartile value ratio (Standardized Hospitalization Ratio, SHR, superior cut-off), Romamedian/3rd quartile values ratio (inferior cut-off) were calculated. These centers were charted in a bar graph and three zones were identified: "excellence" (SHR>1.1), "SHR", "alert" (between the two cut-offs) and "risk" (under the lower cut-off). RESULTS: 35743 thyroidectomies and 2306 parathyroidectomies were performed in Italy in 2015. After the outliers' exclusion, 407 and 157 centers performing respectively thyroidectomies and parathyroidectomies were analysed. A median value of respectively 37 thyroidectomies and 6 parathyroidectomies, and a 3rd quartile cut-off of respectively 85 and 12 were calculated. Concerning all the 666 centers, we found: 95 excellence centers for thyroidectomy and 33 for parathyroidectomy, respectively 18 and 17 falling into superior cut-off line, 100 and 29 in the alert zone, 453 and 587 in the risk zone. CONCLUSIONS: Our method, according to the literature data, highlighted a number of thyroidectomies and parathyroidectomies performed in low volume centers. Looking for an optimization in health organization, we can consider some measures such as a net of tutorship of the "alert" hospitals by the excellence ones and a discouragement of the "risk" hospitals in performing endocrine neck surgery.

The management of the slow transit constipation in the laparoscopic era.

The slow transit constipation (STC) is a functional bowel pathology with slow total gut transit time with normal calibre colon in addition to a variety of other systemic symptoms. Patients with an abnormal colonic motility refractory to conservative treatment are regarded as appropriate candidates for surgery. Laparoscopic total colectomy with ileum-rectum anastomosis represents the commonest surgical operation in the treatment of STC, in well selected patients, after failure of conservative treatment. From 2012 to 2016, 8 patients suffering constipation according to Roma III criteria and diagnosed as STC were submitted to a total colectomy in our O.U. We evaluated the long-term post-operative quality of life and the bowel function, specifically the persistence of constipation and the number of daily bowel movements. Based on our results, we consider that the use of minimally invasive total colectomy with an ileum-rectal anastomosis is the procedure of choice in patients with colonic inertia, and should be performed by experts in laparoscopic colorectal surgery offering a satisfying post-operative quality of life with low morbidity and mortality rates.

Impact of the Reticular Stress and Unfolded Protein Response on the inflammatory response in endometrial stromal cells.

During decidualization, endometrial stromal cells undergo reticular stress (RS) and unfolded protein response (UPR), allowing the endoplasmic reticulum-expansion and immunomodulators production. Physiological RS generates the activation of sensing proteins, inflammasome activation and mature-IL-1ß secretion, associated with pro-implantatory effects. We focus on the impact of RS and UPR on decidualized cells and whether they induce a physiological sterile inflammatory response through IL-1ß production. Human endometrial stromal cell line (HESC) after decidualization treatment with MPA + dibutyryl-cAMP (Dec) increased the expression of RS-sensors (ATF6, PERK and IRE1α) and UPR markers (sXBP1 and CHOP) in comparison with Non-dec cells. Then we found increased NLRP3 expression in Dec cells compared with Non-dec cells. In fact STF-083010 (an IRE1α inhibitor) prevented this increase. Downstream, increased levels of active caspase-1 on Dec cells were detected by FAM-Flica Caspase-1 associated with an increase in IL-1ß production. Moreover, the treatment with STF-083010 decreased the invasion index observed in Dec cells, evaluated by an in vitro model of implantation. In endometrial biopsies from recurrent spontaneous abortion patients an increased expression of IRE1α was found in comparison with fertile women; while recurrent implantation failure samples showed a lower expression of sXBP1, TXNIP and NLRP3 than fertile women, suggesting that RS/UPR tenors might condition endometrial receptivity.

Preliminary results about a novel technique of mesh positioning in the abdominal wall hernia repair.

INTRODUCTION: The surgical techniques described to approach the incisional hernia repair are various and there is not consensus about which of them to use. The Intra-Peritoneal Onlay Technique (IPOM) with classic mesh positioning is burdened by high post-operative complication rate. The study shows the preliminary results of a novel technique of open IPOM mesh positioning with "percutaneous" approach. PATIENTS AND METHODS: From January 2010 to December 2016 patients with abdominal wall incisional hernia that underwent surgical operation via open mesh technique for abdominal wall hernia repair at the "Policlinico Paolo Giaccone" at Palermo University Hospital were identified and the data collected were retrospectively reviewed; patients' medical and surgical records were collected from charts and the surgical registries. One hundred thirty-five patients with open IPOM percutaneous mesh positioning were selected. DISCUSSION AND CONCLUSIONS: The observational study proposed showed that the technique described for the abdominal wall incisional hernia repair seems to be hopeful in order to set a post-operative course not burdened by elevated rate of post-operative complications, estimated to be near 37% vs 13% reported by our series.

The abdominal wall incisional hernia repair in cirrhotic patients.

BACKGROUND: The incidence of abdominal wall hernia in cirrhotic patients with ascites is between 20 and 40%. Controversies regarding the treatment modality and surgical timing of abdominal wall incisional hernia repair in cirrhotic patients remain. The study proposed wants to analyze the abdominal incisional hernia repair in cirrhotic patients with ascites performed in a single center to determine post-operative morbidity, mortality and complication rate. PATIENTS AND METHODS: Cirrhotic patients with abdominal incisional hernia that underwent surgical operation for abdominal wall hernia repair at the "Policlinico Paolo Giaccone" at Palermo University Hospital between January 2015 and December 2016 were identified and the data collected were retrospectively reviewed; patients' medical and surgical records were collected from charts and the surgical and ICU registries. The degree of hepatic dysfunction was classified using Child-Pugh classification. Post-operative mortality was considered up to 30-days after surgery. A follow-up period of 6 months at least was performed to evaluate hernia recurrence and complications. RESULTS: Mortality rate is of 18.5% (p 0.002). Recurrence rate (p 0.004) and seroma formation rate (p 0.001) are most frequent in urgency group. The elevated ASA score and the prediction of a complicated post-operative course is higher in urgency group (p 0.004) as higher is the in-hospital stay (p 0.001) and the ICU stay (p 0.001). CONCLUSIONS: Elective surgery for abdominal wall hernia repair in cirrhotic patients seems to be successful and associated with lower mortality/morbidity rate and recurrence rate than urgency.

Non-Occlusive Mesenteric Ischemia (NOMI) in Parkinson's disease: case report.

Non-occlusive mesenteric ischemia (NOMI) is a severe pathological condition characterized by signs and symptoms of bowel obstruction, intestinal necrosis resulting from acute and/or chronic inadequate blood perfusion, in the absence of an organic vascular obstruction detectable by imaging techniques. A 64 years old man case with a history of Parkinson's disease in high-functioning levodopa treatment is presented. Clinical and radiological signs of intestinal obstruction were observed. He underwent surgical operation with total colectomy and terminal ileostomy for generalized secondary peritonitis due to perforation of sigmoid colon. Ischemic pancolitis was first suspected. In third post-operative day a contrastenhanced CT scan was performed in the evidence of fever and sub-occlusive symptoms. It was found absence of reliable evidence of vascular changes; superior mesenteric artery and vein patency is maintained A NOMI was then diagnosed. NOMI represents about 0.04% of mesenteric artery diseases. It is correlated with a poor prognosis with a mortality estimated of 70-90%. Parkinson's disease, considering neurodegenerative alterations that characterize it, can be considered as a predisposing factor. The combined treatment with high doses of levodopa and vasodilators, such as PGE (Prostaglandin E), can contribute to an improvement in prognosis.

The non-surgical management for hemorrhoidal disease. A systematic review.

The non-surgical treatments for hemorrhoids are cost and time-saving techniques usually performed in patients suffering early hemorrhoidal disease. The most used are rubber band ligation (RBL), injection sclerotherapy (IS), and infrared coagulation (IRC). We performed a systematic review in order to evaluate: do these procedures really help to avoid further more aggressive treatments? What are the common harms? What are the rare harms? How many recurrences there are? A total of 21 RCTs were included in this review: 12 on RBL, 4 on IRC and 5 on IS. In RBL bleeding stops in up to 90% and III degree hemorrhoids improves in 78%-83.8%. IV degree prolapse should have a more invasive treatment. The commonest complications are bleeding and pain (8-80%). IRC related improvement is 78%, 51% and 22% for I, II and III degree. Post-operative pain occurs in 15-100% and post-operative bleeding ranges from 15% to 44%. Recurrence rate is 13% at a three months follow-up. IS brings to the resolution of prolapse in 90%-100% of II degree and allows good results for III degree even if reported only by case series. The post-procedural pain is 36%-49%. Bleeding is a very rare harm. Even if not definitive, these treatments could be an alternative for mild symptomatic patients after a clear explanation of recurrence rates and possible complications.

Deep SSI after mesh-mediated groin hernia repair: management and outcome in an Emergency Surgery Department.

AIM: Mesh-mediated groin hernia repair is considered the goldstandard procedure. It has low recurrence rate. Rarely a deep Surgical Site Infection (SSI) is seen when a synthetic prosthesis is used. CASE REPORT: We describe a rare case of bilateral deep SSI after mesh-mediated groin hernia repair. Diagnosis was performed through the physical examination and radiological exams. Microbiological samples identified a methicillin-resistant Staphylococcus aureus responsible of the infection. Target therapy was performed and re-operation performed in order to remove the infected prosthesis and to apply a biological one to create the fibrous scaffold. During follow-up time, right side recurrence was observed. Tru-cut biopsy of fascia was obtained in order to identify the responsible of the recurrence. CONCLUSION: Combination of antibiotic therapy and surgical reoperation seems to be the correct way to approach the deep SSI after mesh-mediated groin hernia repair. The use of biological mesh after synthetic removal seems to improve the final outcome.

An investigation of bedside laparoscopy in the ICU for cases of non-occlusive mesenteric ischemia.

BACKGROUND: Acute mesenteric ischemia is a rare affection with high related mortality. NOMI presents the most important diagnostic problems and is related with the higher risk of white laparotomy. This study wants to give a contribution for the validation of laparoscopic approach in case of NOMI. METHODS: Thirty-two consecutive patients were admitted in last 10 years in ICU of Paolo Giaccone University Hospital of Palermo for AMI. Diagnosis was obtained by multislice CT and selective angiography was done if clinical conditions were permissive. If necrosis was already present or suspected, surgical approach was done. Endovascular or surgical embolectomy was performed when necessary. Twenty NOMI patients underwent medical treatment performing laparoscopy 24 h later to verify the evolution of AMI. A three-port technique was used. In all patients we performed a bed side procedure 48-72 h later in both non-resected and resected group. RESULTS: In 14 up 20 case of NOMI the disease was extended throughout the splanchnic district, in 6 patients it involved the ileum and the colon; after a first look, only 6 patients underwent resection. One patient died 35 h after diagnosis of NOMI. The second look, 48 h later, demonstrated 4 infarction recurrences in the group of resected patients and onset signs of necrosis in 5 patients of non-resected group. A total of 15 resections were performed on 11 patients. Mortality rate was 6/20-30% but it was much higher in resected group (5/11-45,5%). Non-therapeutic laparotomy was avoided in 9/20 patients and in this group mortality rate was 1/9-11%. No morbidity was recorded related to laparoscopic procedure. CONCLUSIONS: Laparoscopy could be a feasible and safety surgical approach for management of patient with NOMI. Our retrospective study demonstrates that laparoscopy don't increase morbidity, reduce mortality avoiding non-therapeutic laparotomy.

Laparoscopic ileocecal resection in acute and chronic presentations of Crohn's disease. A single center experience.

INTRODUCTION: The terminal ileum is the most involved tract in Crohn's disease. The obstruction in this location is the most frequent complication. Acute or chronic presentations can occur. Surgery finds a role in the management of chronic strictures and in acute clinical presentations with complications not improving with conservative therapy. PATIENTS AND METHODS: We investigate the outcome of patients with obstruction of the ileo-cecal bowel tract laparoscopically managed. It was analyzed the average operative time (OT), the conversion rate and the occurrence of re-operation due to surgical complications. RESULTS: 21 patients underwent an ileocecal resection for complicated Crohn's disease between January 2013 and December 2014. The admissions were performed in emergency in 42% of patients. The preintervention hospital stay was 5.8 (Sd 6.23). The mean operative time was 154 min (Sd 41). 28% of the procedures were converted to open surgery. The average hospital stay was 10 days (Sd 5) in uncomplicated patients. The morbidity rate was 28%. In 19% of cases a re-intervention was needed due to anastomotic leakage (3pts) and one hemoperitoneum for bleeding from the suture line. DISCUSSION: Laparoscopy seems an affordable technique in the management of obstructive pattern of Crohn's disease. It should be the preferable approach in young patients that probably will be submitted to subsequent surgery for the same disease; in fact, the reduced adhesions formation provided by the less bowel manipulation make easy the subsequent access. Older patients had usually more post-operative morbidity and mortality mostly due to pre-existing conditions; if possible in these patients the treatment should be medical.

Acetylcholine polarizes dendritic cells toward a Th2-promoting profile.

BACKGROUND: A growing body of research shows a reciprocal regulation between the neural and immune systems. Acetylcholine (ACh) is the most important parasympathetic neurotransmitter, and increasing evidence indicates that it is able to modulate the immune response. Interestingly, in recent years, it has become clear that immune cells express a non-neuronal cholinergic system, which is stimulated in the course of inflammatory processes. We have previously shown that dendritic cells (DC) express muscarinic receptors, as well as the enzymes responsible for the synthesis and degradation of ACh. Here, we analyzed whether ACh could also modulate the functional profile of DC. METHODS: Dendritic cells were obtained from monocytes cultured for 5 days with GM-CSF+IL-4 or isolated from peripheral blood (CD1c+ DC). The phenotype of DC was evaluated by flow cytometry, the production of cytokines was analyzed by ELISA or intracellular staining and flow cytometry, and the expression of muscarinic and nicotinic receptors was evaluated by flow cytometry or qRT-PCR. RESULTS: Treatment of DC with ACh stimulated the expression of the Th2-promoter OX40L, the production of the Th2-chemokines MDC (macrophage-derived chemokine/CCL22) and TARC (thymus and activation-regulated chemokine/CCL17), and the synthesis of IL-4, IL-5, and IL-13 by T cells, in the course of the mixed lymphocyte reaction (MLR). Moreover, we found that the stimulation of OX40L, HLA-DR, and CD83 expressions in DC induced by the Th2-promoting cytokine TSLP, as well as the production of IL-13, IL-4, and IL-5 by T cells in the course of the MLR, was further enhanced when DC were treated with TSLP plus ACh, instead of TSLP or ACh alone. CONCLUSIONS: Our observations suggest that ACh polarizes DC toward a Th2-promoting profile.

Multiparametric evaluation of risk factors associated to seroma formation in abdominal wall surgery.

INTRODUCTION: Incisional hernia is one of the main topics in the general surgery since there is not a unanimous consensus concerning to the best surgical methodology to adopt. It seems that prosthetic surgery is the best technique, even if responsible for the development of periprosthetic seroma. The aim of this study is to assess whether the preoperative abnormalities of the bio-humoral parameters may be considered as risk factors for seroma. PATIENTS AND METHODS: From July 2016 to July 2017 at the "Policlinico Paolo Giaccone", Palermo, Department of Emergency Surgery, 56 patients included in this study, underwent laparotomic mesh repair. The inclusion criteria were: age > 18 years, incisional hernia W2R0 according to the Chevrel classification and a monoperator technique. The main variables were: sex, age, BMI, smoke, ASA score, and co-morbidities. Among the main serum-blood variables: natraemia, kalaemia, chloraemia, calcaemia, PCR, level of glucose, creatinine, albumin and proteins in the blood. The data were analyzed using SPSS software. RESULTS: Univariate analysis highlighted hypo- and hyper-natraemia, hyper-kalaemia, hypo-chloraemia, high levels of PCR, hyper-glycemia, low level of serum-blood albumin and proteins, as statistically significant variables. Multivariate analysis revealed a p<0.05 for PCR, hypo-albuminemia and total serum-blood-protein level. CONCLUSIONS: Alterations of pre-operative bio-humoral parameters could be associated to a greater risk of seroma development. A better understanding of such alterations may lead to more efficient risk stratification methods. This could be essential to better address the medical resources, reducing the post-operative complications and the outpatient controls as well as the risk associated to seroma.

Uncommon localizations of hydatid cyst. Review of the literature.

INTRODUCTION: Hydatid disease is an endemic anthropozoonosis with usual localization in liver and lungs. Rarely it localizes in uncommon sites as spleen, skeleton, kidney, brain, cardiac muscle, peritoneum, sub cutis. Complications of uncommon localizations are the same that for usual ones. MATERIAL AND METHODS: Review of the literature on rare and atypical localization of hydatid cysts in soft tissues. Key-words used on Pub-Med [(echinococ OR hydatid) AND (soft tissue OR subcutaneous OR cutaneous)] without time limit. There were found 282 articles; 242 were excluded because of muscular or bone localizations. 40 were coherent. RESULTS: Different variables are taken into account: age, sex, geographic area, anatomic localization of the cyst, dimension, symptoms, signs, mobility, blood exams and specific serological tests, imaging techniques for diagnosis, existing of septa in the structure, treatment, anaesthesia, spillage, neo-adjuvant and adjuvant treatment, follow-up period, recurrent lesions. CONCLUSION: It would be useful create an homogeneous and standardized collection of data of these rare and potentially life-threatening conditions in order to create guide-line of diagnostic and therapeutic process and create (or adopt) unique classification of the lesions.

Open versus laparoscopic approach in the treatment of abdominal emergencies in elderly population.

AIM: To evaluate the role of laparoscopy in the treatment of surgical emergency in old population. PATIENTS AND METHODS: Over-70 years-old patients submitted to emergency abdominal surgery from January 2013 to December 2014 were collected and grouped according to admission diagnoses. These accounted small bowel obstruction, colonic acute disease, appendicitis, ventral hernia, gastro-duodenal perforation, biliary disease. In each group it was analyzed the operation time (OT), the morbidity rate and the mortality rate comparing open and laparoscopic management using T-test and Chi-square test. RESULTS: 159 over 70-years-old patients underwent emergency surgery in the General and Emergency surgery Operative Unit (O.U.) of the Policlinic of Palermo. 75 patients were managed by a laparoscopic approach and 84 underwent traditional open emergency surgery. T-Test for OT and Chi-square test for morbidity rate and mortality rate showed no differences in small bowel emergencies (p=0,4; 0,250,9; p>0,95) and in gastro-duodenal perforation (p=0,9; p>0.9; p>0.95). In cholecystitis, laparoscopy group showed lower OT (T-Test: p= 0,0002) while Chi-square test for morbidity rate (0,1

Rectal bleeding and prolapse not always benign diseases rather anal cancer. The importance of a correct decision making since primary care.

Rectal bleeding is very common in general population with a prevalence of 10-20 %. Primary care physicians have to stratify patients basing on urgency and on the colo-rectal cancer risk and to conduct a decision making for the correct management. We report a case of a 61-years-old woman, complaining rectal bleeding and an anal mass attended to their family doctor who does a visit but without a digital rectal examination and diagnosed a hemorrhoidal prolapse suggesting medical therapy. For the persistence of symptoms she comes to our service from emergency attention. Inspection and digital rectal examination revealed an anal mass. CT scan was performed showing a large anal mass involving half anal circumference. Histologic samples showed an epithelial proliferation compatible with a squamous carcinoma. Oncological consult was requested and a chemo-radiotherapy treatment was proposed. This case report highlights the difficulty when physicians assess patients with anorectal complaints in differentiating anal cancer from benign disease, presumably because symptoms are similar. Primary care physicians must maintain a high index of suspicion of cancer in high-risk population. Sensitization of these colleagues is required since digital rectal examination is of inestimable value to verify the presence of a rectal or an anal mass.