Bioabsorbable synthetic plug in the treatment of anal fistulas.

BACKGROUND: Management of anal fistulas is challenging, because surgeons must aim to obtain complete healing while sparing the sphincter and avoiding fecal incontinence. The optimal treatment method remains unknown. OBJECTIVE: This study assessed the safety and effectiveness of the use of a new synthetic fistula plug made of bioabsorbable polymers in the treatment of cryptoglandular anal fistulas. DESIGN: This study is a retrospective review of a database of patient records. SETTING: : Patients were treated at a general hospital in Italy. PATIENTS: Forty-eight patients (39 men and 9 women; mean age, 49.9 years) with 49 fistulas were treated with the synthetic plug between November 2009 and March 2012. Types of fistula were as follows: 24 superficial transsphincteric, 18 medium transsphincteric, 5 deep transsphincteric, and 1 medium intersphincteric. INTERVENTIONS: The fistula tract was cleaned by using curettage, and a synthetic plug was sized to fit the tract and inserted. A draining seton was used preoperatively in 1 patient. MAIN OUTCOME MEASURES: The outcome measures were complete closure of the fistula, with no discharge/residual fistula (verified by endoanal ultrasonography), perineal pain level (assessed with a visual analog scale), and fecal continence. Follow-up was conducted at 1 week and 1, 3, 6, and 12 months postoperatively. RESULTS: The overall healing rate was 69.3% (34/49 fistulas, 33/48 patients). Eight patients (24.2%) had healing by 3 months after surgery, 21 patients (63.6%) had healed by 6 months, and 4 patients (12.1%) had healed by 12 months. By 3 months, no patient had perineal pain or fecal incontinence. No plug became dislodged, and no patient had the onset of anal stenosis, bleeding, local infection, or any other complication. LIMITATIONS: The number of patients and the retrospective nonrandomized nature of the investigation are limitations of this study. CONCLUSIONS: In patients with cryptoglandular anal fistulas, the use of a bioabsorbable synthetic plug provided a high rate of healing without causing fecal incontinence or other major adverse effects. Larger and randomized studies of this treatment are warranted.

Nonerosive gastroesophageal reflux disease and mild degree of esophagitis: comparison of symptoms endoscopic, manometric and pH-metric patterns.

BACKGROUND: Our aim in the present study was to compare patients presenting with gastroesophageal reflux disease in the presence or absence of mild-grade esophagitis (grade I or II according to the Savary-Miller classification). METHODS: Between 2005 and 2007, 215 patients with gastroesophageal reflux disease (67 with reflux associated with grade I or II esophagitis and 148 without esophagitis) were evaluated at the Department of Surgery, University Hospital Tor Vergata, Rome, and were included in the present study. The evaluations consisted of clinical interviews, endoscopy of the high digestive tract, esophageal manometry and pH monitoring. RESULTS: There was no significant difference between the two groups with regard to age, sex or symptoms. The incidence of heartburn associated with noncardiac chest pain was greater in the esophagitis group than in the dysphagia group. The incidence of hiatal hernia was similar in both groups. Although the motor pattern was similar in both groups, the length of the abdominal esophagus was greater in patients without esophagitis (1.6 cm vs 1.1 cm; P < 0.05). The reflux pattern was nearly identical in both groups. CONCLUSIONS: Gastroesophageal reflux without esophagitis must be regarded not as a milder form of the disease but as part of a single disease. Furthermore, these patients often demonstrate lower rates of symptom improvement after antireflux treatment in comparison with patients with erosive esophagitis. Therefore, further trials to assess the treatment algorithm for these patients are warranted.

"Complex abdominal wall" management: evidence-based guidelines of the Italian Consensus Conference.

To date, there is no shared consensus on a definition of a complex abdominal wall in elective surgery and in the emergency, on indications, technical details, complications, and follow-up. The purpose of the conference was to lay the foundations for a homogeneous approach to the complex abdominal wall with the primary intent being to attain the following objectives: (1) to develop evidence-based recommendations to define "complex abdominal wall"; (2) indications in emergency and in elective cases; (3) management of "complex abdominal wall"; (4) techniques for temporary abdominal closure. The decompressive laparostomy should be considered in a case of abdominal compartment syndrome in patients with critical conditions or after the failure of a medical treatment or less invasive methods. In the second one, beyond different mechanism, patients with surgical emergency diseases might reach the same pathophysiological end point of trauma patients where a preventive "open abdomen" might be indicated (a temporary abdominal closure: in the case of a non-infected field, the Wittmann patch and the NPWT had the best outcome followed by meshes; in the case of an infected field, NPWT techniques seem to be the preferred). The second priority is to create optimal both general as local conditions for healing: the right antimicrobial management, feeding-preferably by the enteral route-and managing correctly the open abdomen wall. The use of a mesh appears to be-if and when possible-the gold standard. There is a lot of enthusiasm about biological meshes. But the actual evidence supports their use only in contaminated or potentially contaminated fields but above all, to reduce the higher rate of recurrences, the wall anatomy and function should be restored in the midline, with or without component separation technique. On the other site has not to be neglected that the use of monofilament and macroporous non-absorbable meshes, in extraperitoneal position, in the setting of the complex abdomen with contamination, seems to have a cost effective role too. The idea of this consensus conference was mainly to try to bring order in the so copious, but not always so "evident" literature utilizing and exchanging the expertise of different specialists.

Evaluation of clinical, laboratory and morphologic prognostic factors in colon cancer.

BACKGROUND: The long-term prognosis of patients with colon cancer is dependent on many factors. To investigate the influence of a series of clinical, laboratory and morphological variables on prognosis of colon carcinoma we conducted a retrospective analysis of our data. METHODS: Ninety-two patients with colon cancer, who underwent surgical resection between January 1999 and December 2001, were analyzed. On survival analysis, demographics, clinical, laboratory and pathomorphological parameters were tested for their potential prognostic value. Furthermore, univariate and multivariate analysis of the above mentioned data were performed considering the depth of tumour invasion into the bowel wall as independent variable. RESULTS: On survival analysis we found that depth of tumour invasion (P < 0.001; F-ratio 2.11), type of operation (P < 0.001; F-ratio 3.51) and CT scanning (P < 0.001; F-ratio 5.21) were predictors of survival. Considering the degree of mural invasion as independent variable, on univariate analysis, we observed that mucorrhea, anismus, hematocrit, WBC count, fibrinogen value and CT scanning were significantly related to the degree of mural invasion of the cancer. On the multivariate analysis, fibrinogen value was the most statistically significant variable (P < 0.001) with the highest F-ratio (F-ratio 5.86). Finally, in the present study, the tumour site was significantly related neither to the survival nor to the mural invasion of the tumour. CONCLUSION: The various clinical, laboratory and patho-morphological parameters showed different prognostic value for colon carcinoma. In the future, preoperative prognostic markers will probably gain relevance in order to make a proper choice between surgery, chemotherapy and radiotherapy. Nevertheless, current data do not provide sufficient evidence for preoperative stratification of high and low risk patients. Further assessments in prospective large studies are warranted.

Helicobacter pylori and gastroesophageal reflux disease.

BACKGROUND: The nature of the relationship between Helicobacter pylori and reflux oesophagitis is still not clear. To investigate the correlation between Helicobacter pylori infection and GERD taking into account endoscopic, pH-metric and histopathological data. METHODS: Between January 2001 and January 2003 a prospective study was performed in 146 patients with GERD in order to determine the prevalence of Helicobacter pylori infection at gastric mucosa; further the value of the De Meester score endoscopic, manometric and pH-metric parameters, i.e. reflux episodes, pathological reflux episodes and extent of oesophageal acid exposure, of the patients with and without Helicobacter pylori infection were studied and statistically compared. Finally, univariate analysis of the above mentioned data were performed in order to evaluate the statistical correlation with reflux esophagitis. RESULTS: There were no statistically significant differences between the two groups, HP infected and HP negative patients, regarding age, gender and type of symptoms. There was no statistical difference between the two groups regarding severity of symptoms and manometric parameters. The value of the De Meester score and the ph-metric parameters were similar in both groups. On univariate analysis, we observed that hiatal hernia (p = 0,01), LES size (p = 0,05), oesophageal wave length (p = 0,01) and pathological reflux number (p = 0,05) were significantly related to the presence of reflux oesophagitis. CONCLUSION: Based on these findings, it seems that there is no significant evidence for an important role for H. pylori infection in the development of GERD and erosive esophagitis. Nevertheless, current data do not provide sufficient evidence to define the relationship between HP and GERD. Further assessments in prospective large studies are warranted.

Endovascular treatment of ruptured pancreaticoduodenal artery aneurysm: The importance of collateral vessels. A case report.

INTRODUCTION: True pancreaticoduodenal artery aneurysm occurrence is infrequent, but it is a fatal disease and accounts for accounts for <2% of all visceral aneurysms. PRESENTATION OF CASE: A 62-year-old man with a two-day history of epigastric pain was admitted at emergency department. CT showed a retroperitoneal haematoma due to a 1.5cm posterior inferior PDA ruptured aneurysm. Angiography had been conducted immediately: both inflow and outflow of the aneurysm were embolized. Another CT scan had been conducted, which revealed residual flow inside the aneurysm sac fed by small collateral vessels. Sub-selective catheterization was repeated and definitive haemostasis was obtained by embolizing the collateral vessels. Postoperative course was uneventful. CT scan follow-up at 36 months showed no abnormalities. DISCUSSION: The incidence rate of pancreaticoduodenal artery aneurysm rupture has been estimated to be less than or equal to 65%. In the case of rupture the treatment is challenging and mortality had been reported up to 50%. Endovascular treatment showed superior results as compared to surgical treatment of aneurysms, especially in emergency settings. CONCLUSION: The authors elucidate the importance of occlusion of inflow and outflow of the aneurysm in conjunction with the occlusion of collateral vessels to avert reperfusion of the sac. Simultaneous handling of celiac axis stenosis is still prone to controversy: no relapse of aneurysm have been reported in patients with celiac axis stenosis at long-term follow-up, simultaneous treatment should be reserved when angiography is alarming for likely hepatic or duodenal ischemia.

THY3 cytology: What surgical treatment? Retrospective study and literature review.

INTRODUCTION: THY3 nodules collects 20% of cytological examinations, with a rate of malignancy by about 20-30%, and represent one of the most controversial topics of scientific debate. In fact, differential diagnosis of follicular lesions, is very difficult, due to the inability of cytology to differentiate between adenomas and carcinomas. Surgery represents the only possible diagnostic and therapeutic approach, but on the type of surgery there is still absolute discordance of opinions. METHODS: We retrospectively analyzed 230 patients undergoing total thyroidectomy for THY3 cytology between May 2007 and September 2013. Subsequently we re-evaluated our results assuming a conservative surgical approach in patients without preoperative contralateral pathological evidence. RESULTS AND DISCUSSION: Our results indicate an incidence of malignancy in THY3 cytology of 29.6% (n = 68/230), in line with literature data; multifocal bilateral carcinoma in 26.5% of patients; 37 incidental carcinomas (16.5%), 15 of which located contralateral at THY3 nodule; nodular hyperplasia in 52.2% of patients. So, according to a conservative surgery, among patients ideally underwent lobectomy (n = 110), we wouldn't recognize 10 of overall 105 malignancies (9.5%) (including bilateral tumors on THY3 and contralateral incidental carcinomas). Thus, these malignancies would be neither diagnosed nor removed during surgery. CONCLUSIONS: We believe these results allow to state that total thyroidectomy is oncologically the most appropriate intervention to make the patient "disease-free". Moreover, our study could serve as a motivation for further research, but maybe is needed a new Consensus Conference to define a surgical protocol universally recognized.

What is a reliable CT scan for diagnosing splenosis under emergency conditions?

Splenosis is a condition in which splenic tissue is present in a non-anatomical position. Implants of splenic tissue can mimic neoplasms and only specific examinations can confirm the correct diagnosis. Here we report a case of a 23-year-old male patient with a history of surgical splenectomy during childhood after trauma. He was admitted to the emergency department with acute bowel obstruction. An abdominal-pelvic computed tomography (CT) scan revealed small bowel obstruction and the presence of two rounded, solid masses located in the rectal-vescical pouch. Quantitative analyses of the different density values in the arterial phase and early portal venous phase demonstrated that these lesions were highly vascularised (92 and 97 Hounsfield Units, respectively). The hypothesis of an ectopic splenic mass was made after evaluation of the CT images and clinical history. The acute bowel obstruction caused by adhesive intestinal syndrome was resolved by surgical adhesiolysis. The smallest mass adherent to the rectum was removed. Histopathologic examination confirmed the benign nature of the lesion, which consisted of splenic tissue.