Thrombotic complications in inflammatory bowel diseases.

Inflammatory bowel disease (IBD), Crohn's Disease (CD) and Ulcerative Colitis (UC) are associated with an increased risk of arterial and venous thromboembolism. A 2 to 3 time fold increased risk of developing thromboembolic complications was reported for IBD patients compared to general population. A systematic literature search was conducted using PubMed, Medline, Scopus, Cochrane database. The key words were: "Inflammatory Bowell Disease", "Crohn's Disease and Thrombosis", "Ulcerative Colitis and Thrombosis", "Thrombosis" and "Inflammatory Bowel Diseases and Thrombosis". Full articles and abstracts were included. Studies such as case reports, letters and commentaries were excluded from the analysis if appropriate data could not be extracted. Although no randomized controlled trials (RCTs) have been established to evaluate the efficacy of thromboprophylaxis in patients with IBD due to the incidence of VTE and PE in such patients, it is highly recommended the adoption of thromboprophylactic measures. Available prophylaxis and treatment options include pharmacological anticoagulant therapy (LMWH-Low Molecular Weight Heparin, Fondaparinux and UH-Unfractionated Heparin) and mechanical prophylaxis. In case of acute VTE patient must be treated with fibrinolytic agents and in selected non-responsive cases vascular surgery. IBD patients have an increased risk of VTE complications. Prophylaxis for VTE should be recommended in all patients who do not show contraindications to treatment.

The SECCA procedure for faecal incontinence: a review.

AIM: The SECCA system is a treatment option for patients with faecal incontinence and was introduced into clinical practice in 2002. Clinical studies of radiofrequency energy to treat patients with faecal incontinence have been published. This article aimed to review all published series to assess the results of this treatment. METHOD: Twelve studies were included. Outcomes analysed included quality of life, the Wexner incontinence score, anorectal manometry and endoanal ultrasound findings. RESULTS: A total of 220 patients from 10 studies were included. In the majority of clinical studies, the SECCA procedure has been shown to be an effective treatment of mild-to-moderate faecal incontinence. CONCLUSION: When patient selection is appropriate, this treatment has demonstrated clinically significant improvements in symptoms, as demonstrated by statistically significant reductions in the Wexner incontinence and quality of life scores.

[Carcinoid tumors of the appendix: when right colectomy?]. / I tumori carcinoidi dell'appendice. Quando l'emicolectomia destra?

Three cases of carcinoid tumour of the appendix (about 0,3 % of all performed appendectomies) has induced the Authors to a review of the literature with the aim to underline the most important biological and pathological findings and the current clinic and therapeutic knowledges. The diagnosis before surgery is rarely made; it is formulated incidentally in most patients by the histological exam during the operation for an appendicitis or during other surgical procedures. The kind of surgical intervention, that is the entity of the surgical demolition, for the treatment of the carcinoid tumours of the appendix is still controversial: appendectomy or right colectomy? It is possible identify, also during the operation for an appendicitis or for other abdominal lesions, criteria that can orient toward a major surgery (size of the neoplasia, subserosal lymphatic invasion, infiltration of the serosa, diffusion in the meso-appendix, location in closeness of the base of the appendix, invasion of the the locoregional lymph nodes, presence of metastases, section ?margins, number of mitoses, cellular pleiomorfism).

[Surgical treatment of Crohn's disease complications. Our experience]. / La terapia chirurgica nelle complicanze della malattia di Crohn. Nostra esperienza.

Thirty-five patients with Crohn's Disease (CD) were observed: 18 have been treated with medical therapy and 17 (48.6%) underwent to surgical treatment : 1) intolerance to the medical treatment in 5.9% (1 case); 2) local complications in 94.1% (16 cases: 6 stenosis, 2 occlusions, 3 abscesses, 3 fistulas, 1 perforation with peritonitis, 1 case toxic megacolon). The operations have been 19: resective interventions 14 (bowel and/or colon resections), conservative interventions 5. The mortality was 0, the morbidity 35,29%. The incidence of the recurrences in a follow up of 5 year was 42,9%. The Authors conclude that the surgery, indicated for the treatment of complications, can be resective surgery (perforating Crohn disease: fistulas, abscess) or conservative surgery (stenosing Crohn disease: stenosis). Recently the conservative intervention are proposed in the treatment of fistulas and abscesses too, but when the inflammation is mild and in patients that underwent to extensive intestinal resection with risk of short bowel syndrome.

[Excision of a schwannoma of the neck: surgical technique]. / Exeresi di uno schwannoma del collo: note di tecnica chirurgica

We present a case of schwannoma of the neck in 49 year old man, symptomatic (paresthesia, cervical mass and dysphagia). After ultrasonography and magnetic resonance of the neck, the patient was operated and excision of the lesion was completely performed. The operation was performed through a cervical approach: the nerves and the vascular and muscular structures were carefully isolated and preserved. The tumour arised from the cervical sympathetic chain. The diagnosis of schwannoma was possible only by histopathologic examen. After 48 months no local recurrence or postoperative complication related to intervention were found. These lesions are uncommon. The identification of the nerve is often difficult until the operation, which is the treatment of choice for the schwannoma.

[Abdominal emergency surgery in the geriatric patients. Our experience]. / La chirurgia addominale d'urgenza nel paziente geriatrico. Nostra esperienza.

The ageing process of general population implies new socio-sanitary problems. Indications for surgical intervention have been modified and enhanced. As far as elective surgery is concerned, the results in elderly subjects do not seem alarming, whereas less satisfactory results have been registered in the patients who underwent an emergency surgical intervention, where nowadays morbidity and mortality still turn out to be high. The Authors have reported their experience of emergency surgery in the geriatric patient. From 1982 to 2002, 718 pts (361 males, 50.3% and 357 females, 49.7%; average age 50 yrs, range 5-92) underwent emergency surgical interventions for abdominal lesions. The pts were subdivided in two groups: group A (> 65 years; 190 pts, 87 males and 103 females; average age 72 yrs, range 66-92); control group B (<65 years; 528 pts, 274 males and 254 females; average age 43 yrs, range 5-65). The results were assessed in terms of morbidity and of the operative and post-operative mortality. Postoperative morbidity proved to be equal to 25.7% (36.3% in the group A, 21.9% in the group B), while intraoperative mortality equal to 0.27%. Postoperative mortality resulted equal to 12.1% (significantly higher in group A pts -- 16.8%- than in group B pts --10.4%). The mortality of the 190 pts belonging to group A was higher in the pts which were presenting respectively 1, 2, 3 or more concomitant diseases. The progressive percentage increase in the number of interventions on elderly pts not only can be due to the demographic increase of old people, but it can also be linked to a change in the surgeon's attitude. At the present time, while elective geriatric surgery implies an acceptable mortality rate (5-8 %), emergency geriatric surgery has not notably modified the prognosis in the last decades and mortality has turned out to be still high (20-30%). We think that it will be possible to obtain better results through geriatric surgery only by reducing emergency interventions as much as possible. In order to do so, it will be important to insist on intervening before the illness, during its natural evolution, requires actions which cannot be postponed. This would lead to positive results not only in terms of mortality and morbidity, which are still considered as the main targets, but also as far as the period of the stay in hospital and costs are concerned.

[Surgery for complicated colonic diverticulitis. Our experience]. / Risultati del trattamento chirurgico nelle complicanze della diverticolite del colon. Esperienza dell'ultimo ventennio.

During the last two decades were observed 422 symptomatic patients with various degree of diverticular disease of the colon. 51 patients underwent surgery: 29 for stenosis (24) or occlusion (5), 4 for fistulas, 18 for perforation. The operations (26 emergencies, 25 elective) included: 21 cases of one-stage resection and anastomosis without protective colostomy, 16 with colostomy, 8 Hartmann's procedures, 7 Mikulicz's operations, 1 suturing of the diverticulum with colostomy. The incidence of complications was 17.6% (9 cases, 7 following emergency surgery and 2 after elective procedures). The intraoperative mortality was zero, while postoperative 5.8% (3 cases, 2 after emergency procedures and 1 following elective surgery). The best results (lowest morbidity and mortality rates) occurred with the radical procedures, especially the resection-anastomosis with or without colostomy, which allowed the removal of the septic focus from the peritoneal cavity and thus a shorter recovery in a high number of cases.

Double concentric craniotomy: Safe and effective technique to achieve an en bloc resection of tumor involving both skull and duraa.

INTRODUCTION: Many tumors can involve the skull. Meningiomas are one of the most common intracranial neoplasms and invasion of the bone was described in 49% of cases. Other neoplastic lesions that can arise in bone, or involve it, are metastases, hemangiomas, aggressive cutis carcinomas and sarcomas. Radical excision is the golden standard of treatment but elevating a bone flap when the tumor involves both the skull and the dura could represent a technical challenge. PRESENTATION OF CASE: We report the technical details of our approach to remove a meningioma involving both skull and dura in a man aged 45. Patient underwent gross total excision and cranioplasty with PEEK custom made prothesis (Synthes™). DISCUSSION: We describe a double concentric craniotomy (DCC) technique where the tumor involving the bone is before left in situ, exposing normal dura, to perform afterwards en-bloc excision with minimal traction of brain surface. CONCLUSION: DCC is a safe and effective technique to remove tumor involving both skull and dural structures under direct vision.

[Use of vasopressin in the treatment of bleeding esophageal varices. Our experiences]. / Impiego della vasopressina nel trattamento delle varici esofagee sanguinanti. Nostra esperienza.

Results obtained in the control of oesophageal varix rupture haemorrhage by intravenous vasopressin perfusion or selective intraarterial administration are reported. This comparative study shows intravenous administration to be the best method since it produces the same therapeutic effects with fewer undesirable side-effects than when administered arterially. In view of the high level of complications caused by selective arterial catheters, this administration method would only appear justified in cases where selective arterial catheterisation is to be carried out in any case.

[Treatment of short bowel syndrome]. / Trattamento della sindrome da intestino corto.

On the basis of personal experience and the latest reports in the literature on the treatment of short bowel syndrome, the clinical and therapeutic aspects of the malabsorption syndrome arising after removal of long segments of the small intestine are analysed with emphasis on the salient features and particularly the critical phase constituted by the transfer from parenteral to enteral and oral nutrition whose importance for the maintenance of life is objectively confirmed by the adaptive response of the remaining small bowel (compensatory hypertrophy).

[Diagnostic and therapeutic problems in angiodysplasias of the digestive tract]. / Problemi diagnostici e terapeutici nelle angiodisplasie dell'apparato digerente.

After a review of recent literature on angiodysplasias of the digestive system, a diagnostic procedure based on personal experience is proposed for haemorrhagic patients. Criteria for the selection of treatment protocols are then proposed for cases where angiodysplasia is recognised as the cause of the bleeding.

[Use of vasopressin in the treatment of acute hemorrhagic lesions of the stomach. Our experience]. / Impiego della vasopressina nel trattamento delle lesioni emorragiche acute dello stomaco. Nostra esperienza.

Since bleeding from acute lesions of the gastric mucosa can cease spontaneously and the mortality rate of emergency surgery is high, conservative treatment is always preferable. Satisfactory results were obtained with continuous infusions of vasopressin in low doses (0.2 U/kg/hr for 8 hours) so that this treatment appears a valid alternative to more recent techniques (somatostatin).

The Angelchik prosthesis in the surgical therapy of reflux oesophagitis. Short and long term results.

The authors report the results acquired from 1981 to 1985 using the Angelchik prosthesis in 22 patients with reflux oesophagitis resisting medical therapy for more than 6 months. Clinical evaluation has been done using Visick scale, as modified by Deakin. Clinical and instrumental controls have been done at 1 month, 12 months and 5-10 years after the operation. Intraoperative mortality and morbidity were zero. Complications directly related to the operation were: transitory dysphagia in 4 cases, persistent dysphagia in 3 cases, transitory gas bloat syndrome in 1 case and persistent gas bloat syndrome in another, persistent stenosis in 1 case and prosthesis dislocation in 6 cases. Clinical results were satisfactory (success rate: 90.9%) only in patients with a short term follow-up (30 days). The full rate of success has come down to 84.2% and 66.6% in patients having follow-ups respectively of 1 year and 5-10 years. The results are truly disappointing and the authors conclude that this procedure is not to be employed.

[Treatment of recurrent or residual calculosis of the choledochus. A comparison of the technics]. / Il trattamento della calcolosi recidiva o residua del coledoco. Tecniche a confronto.

The results of treating residual or recurrent calculosis of the choledochus for the purpose of obtaining elements for deciding whether or not to carry out a given operation in a particular group of patients are reported. Although they do not offer elements of certainty, the results still make it possible to arrive at an indication for endoscopic papillotomy in elderly patients in poor general condition with one or a few calculi and non-dilated choledochus, for choledochotomy in patients with choledochus of normal diameter and with multiple calculi, or for an intervention of biliodigestive drainage (particularly choledochojejunostomy) in patients with multiple calculosis and with dilated choledochus. In cases in which the apparatus of Oddi is the site of an irreversible inflammatory process and has lost its function, transduodenal papillosphincterotomy is justified.

[A case of leiomyoblastoma of the stomach. Clinical and anatomopathologic considerations]. / Su un caso di leiomioblastoma dello stomaco. Considerazioni cliniche ed anatomopatologiche.

Gastric leiomyoblastoma or Martin's myoid tumour or Stout's smooth muscle cell bizarre tumour is a rare benign mesenchymal neoplasia that may become malignant. A personal clinical case is reported and the most important anatomopathological and clinical aspects are reviewed, stress being laid on the importance of identifying the macroscopic and histological features that can point with certainty to malignity and so influence the choice of surgery. This, depending on the situation, may tumorectomy, gastric resection or gastrectomy with exeresis of any metastases.

[Results of endoscopic treatment of choledochal calculosis and cicatricial stenosis of the papilla]. / Risultati con il trattamento endoscopico nella calcolosi del coledoco e nella stenosi cicatriziale della papilla.

The results obtained with endoscopic papillo-sphincterotomy in the treatment of gallstones and cicatricial stenosis of the papilla are reported. The treatment proved effective in 91.3% of patients with papillary stenosis and the incidence of side-effects (cholangitis, pancreatitis, bleeding, perforation) was 7.5%. Endoscopic PST hitherto restricted to cases judge inoperable due to serious concomitant pathologies may be a valid alternative to surgery wherever total sphincter dysfunction can be ascertained.

[Treatment of perforated duodenal ulcer. Our experience]. / Trattamento dell'ulcera duodenale perforata. Nostra esperienza.

Personal experience in the treatment of perforated duodenal ulcers is reported. The 78 patients concerned were divided into two groups (operated on before or after the introduction of anti-HZ antihistamines) and were encountered between 1-1-1972 and 30-12-1986. The results were generally satisfactory: mortality (operative and postoperative) 5.1%; postoperative complications 6.4%; recurring ulceration 1-5 years after surgery 6.4%. The most successful operations (lowest death and complication rates, shortest hospital stay) were simple suturing and suturing combined with superselective vagotomy. Analysis of the results show that the success of the operation was significantly influenced by the following factors: patient's age and general condition, associated diseases, time of onset of the ulceration prior to perforation and above all the length of time between the perforation and the operation i.e. the presence or absence of peritonitis. Simple suturing should always be used where possible, particularly now we have the anti-H2 drugs. Superselective vagotomy combined with suturing is the definitive surgical treatment of choice and produced no deaths or complications in the 13 patients given this treatment.

[A case of leiomyosarcoma of the small intestine. Clinical and anatomopathologic considerations]. / Su un caso di leiomiosarcoma del tenue. Considerazioni cliniche ed anatomopatologiche.

Leiomyosarcoma of the small intestine is a malignant mesenchymal tumour composed of smooth muscle cells from the muscular coat or, rarely, from muscularis mucosae, which in the majority of cases is characterised by a clinically silent development and by an unfavorable prognosis. The considerable difficulty of obtaining a histological definition of the degree of malignancy of the leiomyosarcoma is also typical. The paper reports a clinical case and summarises its main clinical and anatomopathological aspects. In particular, the difficulties of clinical and histological diagnosis of the degree of malignancy are underlined, together with the fact that these have a considerable influence on the possibilities and results of surgical therapy and survival rates.

[Massive intestinal hemorrhage caused by leiomyoma of the jejunum. Report of a case]. / Emorragia intestinale massiva da leiomioma del digiuno. Descrizione di un caso.

Small-bowel leiomyoma is a rare tumour. The authors report a case complicated by severe bleeding. Esophagus-gastro-duodenal endoscopy was not decisive enough, while TC was the most reliable instrumental investigation. Because of dimensions basic than 10 cm, the presence of a pseudocapsule end the absence of cariokinetic figures, the histopathologic test supports the hypothesis that it was a benign disease. One year follow-up, negative for relapse, confirm that the lesion is benign.