Intra-operative enteroscopy for the identification of obscure bleeding source caused by gastrointestinal angiodysplasias: through a balloon-tip trocar is better.

AIM: Intra-operative enteroscopy (IE) is a valid diagnostic tool which can be adopted in order to identify the precise location of bleeding gastrointestinal angiodysplasias (GIADs) of the small bowel. We describe a novel IE technique that may increase the diagnostic yield by maintaining a steady distension of the bowel and that prevents microtrauma to the intestinal mucosa and spillage of enteric content into the operative field. METHODS: After laparotomy, a centimetric transverse enterotomy is performed approximately at the middle of the small bowel. A 12-mm trocar with balloon is then introduced and insufflated. The small bowel is gently distended by carbon dioxide insufflation. Through the trocar, a paediatric colonscope is then inserted and the enteroscopy is performed either retrogradely to the duodenum or anterogradely to the caecum. Once located, surgery is tailored to the precise site of bleeding, with a consequent sparing of intestinal resection. RESULTS: IE with 12-mm trocar with balloon was adopted in four elderly patients undergoing surgery for bleeding GIADs. The length of small bowel resection ranged from 10 to 200 cm, depending on the number of GIADs. Operating time ranged from 210 to 275 min. Intra-operative blood loss was nil. No patient developed organ-space or wound infections. There was no recurrence of bleeding from the midgut. CONCLUSION: Performing IE through a balloon trocar may increase the diagnostic accuracy of the procedure with the benefit of reducing the risk of traumatic injury to the bowel and the risk of surgical site infection.

The tip of the iceberg of colorectal perforation from enema: a systematic review and meta-analysis.

BACKGROUND: Although rare, perforation following an enema used to treat constipation is a dangerous complication. However, no recommendations or guidelines for enema use are available. So, in common clinical practice, the diagnostic approach and the treatment are not standardized. In an attempt to resolve this clinical dilemma associated with high mortality and potential medicolegal claims for malpractice, we have performed a systematic review and meta-analysis of studies reporting on colorectal perforation secondary to enema use for adult patients with constipation. METHODS: A systematic search of PubMed, Web of Science and Scopus was performed according to the PRISMA statement up until February 2020. Studies that reported on colorectal perforation from enema use in adult patients with constipation were included. The primary outcomes were the rate of hospital mortality and pooled prevalence estimates of mortality from perforation secondary to enema use. The secondary outcomes were the administration of rectal enemas, site of visceral perforation, signs, symptoms, radiological evaluation, and type of treatment RESULTS: A total of 15 studies were included in the final analysis (49 patients). Across all studies, the pooled prevalence estimate of mortality for patients with perforation secondary to enema use was 38.5%, (95% CI [22.7%, 55.5%]). This rate was lower in patients who had surgery (35%) than in patients treated conservatively (57.1%). The sites of perforation were intraoperatively reported in 84% of cases, but in 16% of patients the rectal perforation was undiagnosed, and surgical decision making was problematic. The primary location of the perforation was the rectum in 80.9% of the patients. The enema was administered by a nurse in 90% of the cases, self-administered in 7.5% and a family doctor in 2.5%. The main objective of emergency surgery in this setting is resection of the perforation caused by the enema; when it is not possible to resect the perforated rectum, faecal diversion is needed. Hartmann's procedure was most commonly performed by the surgeons in this review (60.7%), with other reported treatments included a diverting proximal loop colostomy and sigmoid segment exteriorization CONCLUSIONS: Considering the studies available, it is not possible to undertake a thorough evaluation of enema use, including the associated complications and their management. Further data are required to allow the development of guidelines to advice on safe enema use and management of complications.

Molecular genetic features and risk assessment in a series of 30 patients who underwent an operation for gastrointestinal stormal tumours.

BACKGROUND: The objective of the study was to investigate the relationship between molecular genetic features and the standard criteria of risk assessment in patients affected by gastrointestinal stromal tumours (GISTs). METHOD: A review was conducted of a series of 30 patients, with a mean age of 67 years, who underwent surgery for primary GISTs. R0 resection was accomplished in 27 patients. CD117, CD34 desmin, vimentin, S-100 and smooth muscle actin were immunohistochemically tested to achieve a diagnosis of GIST. The loss of wild-type KIT or platelet-derived growth factor receptor alpha (PDGFRα) genes was investigated by sequencing the tumour DNA. RESULTS: Tumour genes mutations were reported in 23 patients (77%), and wild-type in seven. Mutations on the KIT gene occurred in 18 patients, and mutations on the PDGFRα gene in five. The average sizes of the GIST were 8.7 cm, 5.4 cm and 5.9 cm for KIT gene-mutated, PDGFRα gene-mutated and wild-type tumours, respectively. KIT gene mutations were detected in 50% of gastric and in 70% of extragastric GISTs. Moreover, 70% of tumours with a mitotic rate ≥ 5 x 50 highpower fi elds (HPFs) underwent KIT gene mutations. Conversely, PDGFRα mutations were observed only in gastric GISTs with a mitotic rate ≤ 5 x 50 HPFs. By stratifying GISTs according to classes of risk, KIT mutation was shown in most of the high-risk tumours. PDGFRα mutations occurred exclusively in lower classes of risk. CONCLUSION: Molecular analysis data might have a role as a prognostic variable in models of risk assessment for patients with GISTs.

Reed bed systems for sludge treatment: case studies in Italy.

In recent years, reed bed systems (RBSs) have been widely considered as a valid technology for sludge treatment. In this study are presented results about sludge stabilization occurring within beds in four RBSs, situated in Tuscany (Italy). The results showed that stabilization of the sludge over time occurred in all RBSs, as shown by the low content of water-soluble carbon and dehydrogenase activity, which measures indirectly the overall microbial metabolism, and by the re-synthesis of humic-like matter highlighted by the pyrolytic indices of mineralization and humification. Results about heavy metal fractionation, an appropriate technique to estimate the heavy metal bioavailability and sludge biotoxicity, showed that the process of sludge stabilization occurring in RBSs retains metals in fractions related to the stabilized organic matter, making metals less bioavailable. Moreover, the concentrations of various toxic organic compounds were below the limit of concentration suggested by the European Union's Working Document on Sludge, for land application. The effectiveness of the stabilization processes in RBs was hence clearly proven by the results that measured mineralization and humification processes, and by the low levels of bioavailable heavy metals and toxic organic compounds in stabilized sludges.

Cholecystokinin CCK2 receptors mediate the peptide's inhibitory actions on the contractile activity of human distal colon via the nitric oxide pathway.

BACKGROUND AND PURPOSE: Cholecystokinin is known to exert stimulant actions on intestinal motility via activation of type 1 cholecystokinin receptors (CCK(1)). However, the role played by cholecystokinin 2 (CCK(2)) receptors in the regulation of gut motility remains undetermined. This study was designed to examine the influence of CCK(2) receptors on the contractile activity of human distal colon. EXPERIMENTAL APPROACH: The effects of compounds acting on CCK(2) receptors were assessed in vitro on motor activity of longitudinal smooth muscle, under basal conditions as well as in the presence of KCl-induced contractions or transmural electrical stimulation. KEY RESULTS: Cholecystokinin octapeptide sulphate induced concentration-dependent contractions which were enhanced by GV150013 (CCK(2) receptor antagonist; +57% at 0.01 microM). These effects were unaffected by tetrodotoxin. The enhancing actions of GV150013 on contractions evoked by cholecystokinin octapeptide sulphate were unaffected by N(omega)-propyl-L-arginine (NPA, neuronal nitric oxide synthase inhibitor), while they were prevented by N(omega)-nitro-L-arginine methylester (L-NAME, non-selective nitric oxide synthase inhibitor). In the presence of KCl-induced contractions, cholecystokinin octapeptide sulphate elicited concentration-dependent relaxations (-36%), which were unaffected by NPA, but were counteracted by GV150013 or L-NAME. The application of electrical stimuli evoked phasic contractions which were enhanced by GV150013 (+41 % at 0.01 microM). CONCLUSIONS AND IMPLICATIONS: CCK(2) receptors mediate inhibitory actions of cholecystokinin on motor activity of human distal colon. It is suggested that CCK(2) receptors exert their modulating actions through a nitric oxide pathway, independent of the activity of the neuronal nitric oxide synthase isoform.

Total anorectal reconstruction supported by electrostimulation gracilis neosphincter.

PURPOSE: To review and to update the results of Total Anorectal Reconstruction with Electrostimulated Graciloplasty (ES-TAR) at the same time as or following abdominoperineal resection (APR). SETTING: A university hospital in Italy. METHODS: Retrospective study. POPULATION: A series of 98 consecutive anorectal cancer patients who had undergone ES-TAR (in 88 cases at the same time as APR; in 10 cases following APR), 61 of whom are still evaluable in respect of continence (median follow-up period 55 months). RESULTS: There was no mortality. Thirty-seven percent of patients had postoperative complications with no impact on survival or functional outcome. The 5-year survival rate in 50 patients was 61% and the 5-year estimated cumulative probability of survival in 81 patients was 65%. Local recurrence rate was 16%. Continence was achieved in 87% of patients with a chronically stimulated TAR, and in 69% of patients with short-term stimulation. CONCLUSION: ES-TAR is a safe and effective method for both curing anorectal cancer and restoring continence. It may be considered a reliable alternative to sphincter-saving procedures in lower rectal cancer patients.

Subcutaneous implantation of liver metastasis after fine needle biopsy.

A 50-year-old woman underwent percutaneous ultrasonographic fine needle biopsy of a suspicious liver metastasis of colon cancer. A subcutaneous metastasis developed at the site of the puncture 20 days after biopsy. Tumor recurrence in the needle biopsy track is rarely reported in the literature. The possible causes of this complication are discussed.

Effect of blood transfusions on disease-free interval after rectal cancer surgery.

BACKGROUND/AIMS: To assess retrospectively the impact of perioperative blood transfusions on disease-free interval after curative surgery of rectal cancer. METHODOLOGY: One hundred and seven (107) subjects (65 men and 42 women, median age: 67) underwent anterior resection of the rectum for rectal cancer between 1990 and 1996. Thirty-six (37%) were transfused perioperatively. Outcome variables measured were: age, sex, distance of the tumor from the anal verge, type of stapled anastomosis, protective colostomy, cancer-free margin in the specimen, grading and staging, leak of the suture line, transfusion, number of blood units given, and adjuvant therapy. RESULTS: Transfusion, nodes involvement and adjuvant therapy had a significant impact on disease-free interval at the univariate analysis. The estimated probability of cancer-free survival at 5 years was 81% for the not transfused, and 63% for the transfused patients (P < 0.05). At multivariate analysis, nodes involvement resulted significantly and independently related to time to recurrence (P < 0.05) but also perioperative blood transfusion showed an important role as independent risk factor for rectal cancer relapse (P = 0.05). CONCLUSIONS: This study suggests that blood transfusion is likely to have a detrimental effect on disease-free interval after resective surgery of rectal cancer.

Laparoscopic sonography: a real alternative to cholangiography during laparoscopic cholecystectomy?

BACKGROUND/AIMS: The routine use of intraoperative cholangiography (CGP) during laparoscopic cholecystectomy (LC) is still under debate. Previous reports suggest that intraoperative sonography can replace CGP in the evaluation of common duct lithiasis during open cholecystectomy. The present study was performed to evaluate the possible role of sonography during LC. PATIENTS AND METHODS: 45 patients were submitted to laparoscopic sonography of biliary tree during LC. In all cases, CGP was performed. RESULTS: In 37 cases, sonography did not show the presence of stones; in 7 cases, common bile duct stones were identified by sonography; one false negative was observed. A sensitivity of 87.5%, a specificity of 100% and an overall accuracy of 97.8% were obtained. A false positive was obtained with CGP with a sensitivity of 100%, a specificity 97.3%, and an overall accuracy of 97.8%. CONCLUSIONS: Laparoscopic sonography can represent an adequate substitute for CGP as a screening procedure during LC.

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment.

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.

Single and double stapled anastomoses in rectal cancer surgery; a retrospective study on the safety of the technique and its indication.

Low anterior resection is commonly believed the main indication to double stapled (DS) technique, because placing the purse-string suture on the distal rectum is difficult or impossible. This study was designed to figure out the safety of the DS technique and to better define its role in rectal cancer surgery. The data of 34 patients that had a DS anastomosis were retrospectively compared to those of 43 that had a single-stapled (SS) anastomosis after anterior resection. Three deaths after SS (7%) and one after DS procedures (3%) were recorded (p = 0.62). Rates of clinical leaks were 12% (four cases) in the DS group and 14% (six cases) in the SS group (p = 0.41). The mean distance of the rectal tumour from the anal verge was significantly lower for DS (mean = 7.7 cm) respect to SS (mean = 12.7 cm) anastomoses (p < 0.0001) and the blood consumption at surgery was significantly greater in patients that had DS (mean = 375 ml) compared to SS-anastomoses (mean = 180 ml) (p = 0.028). Thus, the DS technique was mostly used in patients at high risk for leakage. The study shows that DS technique is a safe and reliable method to perform colorectal anastomosis after anterior resection for cancer. For cancers located in the upper rectum the routine adoption of the DS increases the cost of surgery and does not offer advantages over the SS technique with the exception of making feasible end-to-end mechanical anastomoses involving bowel segments having different diameters.

Association between perioperative blood transfusion and dehiscence of anastomosis after rectal resection for cancer.

Perioperative blood transfusion (PBT) has proved to increase the risk of sepsis after surgery. The hypothesis that PBT also might increase the occurrence of leak of rectal anastomoses has been tested. The data of 94 patients undergone low anterior resection for rectal cancer were reviewed. Thirty-nine of them (41%) received one or more packed red cells (PRC) units perioperatively. The total dehiscence rate was 14% (13 cases), and it was significantly lower in not-transfused (4%) compared to transfused patients (28%) (p < 0.005). The risk of dehiscence was increased by six-fold if up to two, and by fifteen-fold if more than two PRC units were given. These findings suggest that leakage of rectal anastomoses should be considered among the detrimental effects of PBT. The risk of dehiscence increases with the number of units transfused. A judicious administration of blood might contribute to reduce this complication.

"What you see is not what you get". A plea to remove a 'normal' appendix during diagnostic laparoscopy.

BACKGROUND: Diagnostic laparoscopy (DL) is a well established alternative option to coeliotomy for suspected appendicitis. When a 'normal' appendix is found, appendectomy is often believe unnecessary. Little is known however about how normal a normal appearing appendix is. In this study we postulated that a normal appendix seen at DL, may show pathological indications at microscopy, and thus, to leave the appendix untouched may be unsafe. METHODS: A retrospective review of data from 48 patients which, in a five year period (1995-1999), had virtually normal appendices removed as completion of DL for lower abdominal pain. RESULTS: No procedure-related drawback and no subsequent complications were recorded. Symptoms subsided in all the patients. Mean hospital stay was 2.1 days. When receiving specimens, incidence of pathologic changes of the appendix were observed in 58 percent of the cases (n = 28). The negative predictive value of DL was 41 percent. CONCLUSIONS: Due to the consistently false negative rate of DL, and the low morbidity rate for laparoscopic appendectomy, we support incidental appendectomy in patients with lower abdominal pain.

[Arterio-venous popliteal fistula: a rare late complication of a civilian trauma. A clinical case and review of the literature]. / Fistola artero-venosa poplitea: rara complicanza tardiva di un trauma civile. Caso clinico e revisione della letteratura.

In spite of the relatively high frequency of popliteal injuries following war and civilian traumas, a late development of an arteriovenous fistula can be considered an uncommon complication. We report a case of a chronic arterio-venous popliteal fistula in a young boy, caused five years previously by a blunt trauma, while playing. The tardive onset of symptomatology and the conspicuous enlargement of the vein underline the unusuality of the case. A review of the literature and the technique for fistula repair, using adsorbable suture, are examined.

[Hepatic metastases of colorectal carcinoma. Case reports]. / Metastasi epatiche da carcinoma colo-rettale. Note di casistica.

Authors report their clinical experience concerning liver metastases from colorectal cancer. 21 (26%) out of 87 patients observed between 1977 and 1988, underwent hepatic resection. In this group the recorded operative mortality was 4.7% and the postoperative follow-up showed a survival rate of 27% five years after hepatic surgery. Hepatic resection should be considered as the most effective treatment for liver metastases from large bowel cancer. Unfortunately only few patients are suitable for surgery. Alternative treatments for unresectable hepatic recurrences of colorectal cancer still remain a most major problem.

[Use of defibrotide in the treatment of acute superficial thrombophlebitis of the legs]. / Impiego del defibrotide nel trattamento delle tromboflebiti acute superficiali degli arti.

The efficacy of defibrotide in the treatment of acute thrombophlebitis of the legs has been investigated in 140 patients, randomized into two groups. All patients received defibrotide either alone or as an addition to conventional therapies. Two different schemes of administration were selected and carried out in each group, according to the time of onset of thrombophlebitis. Defibrotide demonstrated a good clinical efficacy in both groups, with a highly significant reduction in those patients receiving defibrotide and conventional therapies. The clinical result were outstanding in two subgroups: extensive thrombophlebitis and brachioaxillary phlebitis.

[The prevention of postoperative deep venous thrombosis with heparan sulfate per os. A controlled clinical study vs. heparin calcium]. / Prevenzione della trombosi venosa profonda postoperatoria con eparansolfato per os. Studio clinico controllato vs eparina calcica.

The paper reports the results of a randomised study carried out on a pool of 100 patients undergoing surgery in order to assess the efficacy and tolerability of orally administered heparan sulfate versus heparin calcium in the prevention of postoperative deep-vein thrombosis. Despite the limits of oral administration, heparan sulfate is indicated in the pharmacological prevention of postoperative deep-vein thrombosis.

[Intestinal reconstruction after a Hartmann intervention: a high-risk procedure?]. / Ricostruzione intestinale dopo intervento di Hartmann: una procedura ad alto rischio?

BACKGROUND/AIM: Restoration of the bowel continuity after Hartmann's procedure has been reported to carry a high rate of both general and anastomosis-related complications. Aim of the study was to test the hypothesis of the Hartmann's procedure reversal as high-risk surgery. STUDY DESIGN, SETTING: Retrospective analysis of a cases series, University hospital, Italy. MATERIAL: Forty patients (male n = 25; female n = 15) with a mean age of 64.8 yrs. (range 35 to 82 yrs.) who underwent manual (n = 4; 10%) or stapled (n = 36; 90%) colorectal anastomosis. The mean interval between the Hartmann's procedure and the colostomy closure was 259 days. MAIN OUTCOME MEASURES: Mortality, morbidity, anastomotic complications. RESULTS: No death was recorded. The overall complication rate was 37.5 per cent (n = 15 patients), being wound infection the most common (n = 9). Complications of the colorectal anastomosis were observed in n = 5 patients (12.5%). In details, four patients (10%) developed stenosis of the anastomosis and one (2.5%) bled from the suture line. No instance of leak was observed. Surgery was required to correct a recurrent stenosis of the colorectal anastomosis. CONCLUSION: Restoration of the bowel continuity after Hartmann's procedure is safe and has an acceptable rate of general and anastomosis-related morbidity. Most of the anastomotic complications will resolve without further surgery.

[Prognostic risk factors in patients operated on for perforated peptic ulcer. A retrospective analysis of critical factors of mortality and morbidity in a series of 40 patients who underwent simple closure surgery]. / Fattori di rischio prognostico in pazienti operati per ulcera peptica perforata. Analisi retrospettiva dei fattori critici per la mortalità e morbilità su una serie di 40 pazienti sottoposti ad intervento di sutura semplice.

STUDY OBJECTIVE: To identify factors affecting mortality and morbidity in patients operated on for perforated peptic ulcer. DESIGN: Retrospective analysis. SETTING: University Hospital, Italy. PATIENTS: Forty patients consecutively operated on for perforated peptic ulcer by simple suture procedure performed either by laparotomy (n = 26) or laparoscopic (n = 14) approach. MEASUREMENTS AND MAIN RESULTS: Mortality was 20% (n = 8) and morbidity in survivors was 25% (n = 8). Compared to survivors, non-survivors were older (mean age 79.3 yrs. vs 60.0 yrs., p < 0.01), had worse APACHE II and SAPS scores (mean 20.1 vs 8.5, p < 0.001; and 13.1 vs. 5.5, p < 0.0001 respectively), were treated later (mean interval from outbreak of symptoms to surgery 30.8 hrs. vs. 11.1 hrs., p < 0.01), and the size of their perforation was larger (mean 15.1 mm. vs. 8.6 mm, p < 0.05). The laparoscopic approach was the only factor that significantly was associated with morbidity in survivors (p < 0.01). The presence of at least two risk factors, enhanced the probability of death. CONCLUSION: Old age, great APACHE II and SAPS scores, delay in treatment and large size of the perforation were associated significantly to mortality in perforated peptic ulcer patients. Efforts should be made perioperatively for patients having these risk factors.

Role of cyclooxygenase isoforms in the altered excitatory motor pathways of human colon with diverticular disease.

BACKGROUND AND PURPOSE: The COX isoforms (COX-1, COX-2) regulate human gut motility, although their role under pathological conditions remains unclear. This study examines the effects of COX inhibitors on excitatory motility in colonic tissue from patients with diverticular disease (DD). EXPERIMENTAL APPROACH: Longitudinal muscle preparations, from patients with DD or uncomplicated cancer (controls), were set up in organ baths and connected to isotonic transducers. Indomethacin (COX-1/COX-2 inhibitor), SC-560 (COX-1 inhibitor) or DFU (COX-2 inhibitor) were assayed on electrically evoked, neurogenic, cholinergic and tachykininergic contractions, or carbachol- and substance P (SP)-induced myogenic contractions. Distribution and expression of COX isoforms in the neuromuscular compartment were assessed by RT-PCR, Western blot and immunohistochemical analysis. KEY RESULTS: In control preparations, neurogenic cholinergic contractions were enhanced by COX inhibitors, whereas tachykininergic responses were blunted. Carbachol-evoked contractions were increased by indomethacin or SC-560, but not DFU, whereas all inhibitors reduced SP-induced motor responses. In preparations from DD patients, COX inhibitors did not affect electrically evoked cholinergic contractions. Both indomethacin and DFU, but not SC-560, decreased tachykininergic responses. COX inhibitors did not modify carbachol-evoked motor responses, whereas they counteracted SP-induced contractions. COX-1 expression was decreased in myenteric neurons, whereas COX-2 was enhanced in glial cells and smooth muscle. CONCLUSIONS AND IMPLICATIONS: In control colon, COX-1 and COX-2 down-regulate cholinergic motility, whereas both isoforms enhance tachykininergic motor activity. In the presence of DD, there is a loss of modulation by both COX isoforms on the cholinergic system, whereas COX-2 displays an enhanced facilitatory control on tachykininergic contractile activity.