The uncertain primary diagnosis of inflammatory bowel diseases.

BACKGROUND: The purpose of this study is to re-evaluate our series of patients affected by a colonic non-neoplastic disease, in order to measure the percentage in whom we were unable to make a correct diagnosis after the first clinical and histological approach and to single-out the reasons for our inability to reach the correct diagnosis. METHODS: During the period 1985-1999 we observed 1228 patients affected by chronic inflammatory colonic diseases. RESULTS: In 859 patients (69.9%) an ulcerative colitis was diagnosed for the first time, and 248 patients (20.1%) were affected by Crohn's colitis. One hundred and twenty-one patients (9.8%) were defined as being affected by an undetermined colitis. Forty-three patients of these had a definite diagnosis, afterwards: 27 patients were affected by ulcerative colitis and 16 by Crohn's colitis. Differential diagnosis between inflammatory large bowel diseases (ILBD) and other forms of colitis was set out as follows: 62 cases out of 1228 were consequent on a bacterial infection or parasitosis; in 28 patients a colitis pseudomembranosus was diagnosed. Eighteen cases of ischemic colitis are reported and 14 patients were affected by NSAID-related colitis. In another 6 patients we diagnosed a postradiation colitis. In 22 cases mimicking a Crohn's colitis we ascertained 9 patients affected by intestinal lymphoma, 11 mycobacterium tuberculosis related intestinal infections and 2 cytomegalovirus related colitis. CONCLUSIONS: Despite progress in scientific acquisitions and in diagnostic methods, correct initial diagnosis of ILBD is still difficult, even though it will be defined with time.

One-day vs standard thyroidectomy. A perspective study of feasibility.

BACKGROUND: The aim of this randomized controlled trial is to evaluate the feasibility of one-day thyroidectomy, comparing the results of this method vs standard thyroidectomy. METHODS: From June 2000 to June 2001, 110 patients underwent total thyroidectomy under general anesthesia for thyroid disease. The patients were randomized into 2 groups: in group A (40 patients) we used the one-day thyroidectomy; in group B (70 patients) we employed standard thyroidectomy. In both groups postoperative mobilization was immediate and the mean postoperative hospitalization stay was 21 hours (range: 18-24) in group A and 60 hours (range: 21-120) in group B. The mean follow-up was 10 months (range: 6-18 months). RESULTS: The patients of group A showed hypoparathyroidism with temporary hypocalcaemia in 3 cases (7.5%) vs 5 (7.1%) of group B; this finding was not statistically significant. No cases of definitive hypoparathyroidism, nor lesions of RLN, of the external branches of the superior laryngeal nerve, nor postoperative hemorrhage were observed in either group. CONCLUSIONS: The one-day thyroidectomy was found to be a safe, feasible and cost effective procedure, it is convenient for both the patient and the surgeon, and offers the same immediate and long-term results as the standard thyroidectomy in selected patients.

Rectal perforations. Personal experience and literature review.

BACKGROUND: Rectal perforation presents high morbidity and mortality and its treatment is still not standardized, it is still rather based on the surgeon's personal experience. This retrospective trial, with a literature review, aims to define these types of lesions, and tries to identify the diagnostic and therapeutic options able to reduce related morbidity and mortality. METHODS: On 1175 operations conducted for colo-rectal emergency, over a ten-year period at our institution, fourteen consecutive patients (1.2%) were seen and treated for rectal perforation. In 43% of cases the treatment consisted in Hartmann's procedure, in the 28.5% ones in rectal wound repair with diverting colostomy and in 28.5% left in diverting colostomy alone. RESULTS: There were no postoperative complications in 86% of patients, and no deaths from sepsis. In 28.5% of cases intestinal continuity was restored at our institution. CONCLUSIONS: Our results demonstrate that a standardized protocol which is based on patients' conditions, type and degree of rectal injury and of peritonitis, must be followed in order to determine the type of surgical option and consequently to reduce the morbidity and mortality related to rectal perforation.

Trabucco versus Rutkow versus Lichtenstein techniques in the treatment of groin hernia. A controlled randomized clinical trial.

BACKGROUND: The aim of this prospective study is to compare the results of the 3 most common tension-free techniques usually performed (Trabucco vs Rutkow vs Lichtenstein). METHODS: From January 1993 to December 1995 we selected 150 patients to undergo elective surgery for primary monolateral inguinal hernia. The patients were randomized into 3 groups: in group A (53 patients) we used the original plug and patch technique proposed by Rutkow and Robbins; in group B (47 patients) we introduced a modification to the technique originally described by Trabucco, anchoring the plug to the internal ring, fixing the patch on the pubic tubercle and on the tails of the mesh; in group C (50 patients) the Lichtenstein technique was employed. The study was performed using a randomized single blind controlled trial (RCT). The statistical analysis of our data was performed by c2 test and confirmed by the Fisher exact test. The mean follow-up was 73 months (range:58-94). RESULTS: We had no statistically significant differences in the results of the 3 groups. Otherwise the patients of group C showed a significantly higher incidence of suprapubic or more rare inguino-scrotal haematoma (p<0.0033 C vs B; p <0.0038 C vs A). The mean recovery time was between 12 and 14 days in the 3 groups, with no significant statistical differences. CONCLUSIONS: The only difference observed is a higher incidence of postoperative haematoma in group C.

[The indications and surgical treatment in the complications of colonic diverticular disease]. / Indicazioni e trattamento chirurgico nelle complicanze della malattia diverticolare del colon.

In this work the authors describe the different stages of diverticulosis and analyze the pathogenetic principal factors. During the period from 1979 to 1998 they observed 420 patients affected by diverticular disease (224 M; 196 F), 42 (10%) of them were operated on for complications. Fifteen patients operated on in elective time underwent a one stage procedure of resection and anastomosis with derivative colostomy; 27 patients were operated on in emergency: 6 patients had one stage procedure of resection and anastomosis with derivative colostomy, 16 patients Hartmann's procedure, 3 patients Mikulicz's procedure and 2 patients colostomy and peritoneal drainage. Two patients died from septic shock. There was absence of postoperative complications for the patients operated on in elective time, while 8 cases (29.6%) showed peritoneal sepsis and 4 cases (14.8%) infection of wound in the patients operated on in emergency. The Authors describe the different surgical options in the treatment of colonic complicated diverticular disease and conclude that the surgical treatment is not definite. A tendency is to make a one-stage procedure of resection and anastomosis and to reduce the Hartmann's procedure or the simple colostomy with drainage of abdominal cavity.

[Cell-mediated immunity and delayed hypersensitivity study in splenectomy patients: a comparative evaluation between IFN-gamma and skin tests]. / Studio dell'immunità cellulo-mediata e dell'ipersensibilità ritardata negli splenectomizzati: valutazione comparativa fra IFN gamma e skin tests.

The authors of this paper attempt to indicate a feasible, easy-to-use and inexpensive instrument for daily assessing and monitoring of splenectomized subjects to see if they are immunocompromised. Skin tests which are considered easy and inexpensive, may be useful for immunological investigation if their effectiveness is considered equal to that of more difficult and expensive methods. They have also assessed the effectiveness of ST in the study of specific cell-mediated immunity in general and also in cases of delayed hypersensibility, comparatively to serum IFN gamma dosage. The latter is produced by Th1 lymphocytes and Natural Killer cells and is considered a reasonable indicator of cell-mediated immunity and Th1-related delayed hypersensibility. The results of this study confirm that ST is effective in 100% of all splenectomized patients compared to positivity of 60% for the compromise of the immunocompetent system revealed by serum IFN gamma dosage in the same sample of patients. In addition, the fundamental role of other cytokines was confirmed. These include IL-2 which is produced by Th1 lymphocytes and whose lack of results in splenectomized patients are immunocompromised. This is revealed not only by IFN gamma dosage but also by ST.

[Appendiceal carcinoid. Clinical observations and therapeutic considerations]. / Il carcinoide dell'appendice. Osservazioni cliniche e considerazione terapeutiche.

The Authors report 3 cases of carcinoid of the appendix discussing the difficult preoperative diagnosis and the different therapeutical options. Between May 1998 and August 1999 36 appendicectomies were performed, in 18 males and 18 females (age 14-89 years; m. a.: 51.5 years). In 3 cases histological response was positive for carcinoid of the appendix. No postoperative mortality or morbility was reported. In one case, the malignancy of histological response made a second operation of typhlectomy necessary, without postoperative complications. The Authors analyze the biological peculiarities and the prognostic factors of appendiceal carcinoid tumors, as size of the tumor and the lymphatic or vascular infiltration of the mesoappendix (and the relative more aggressive surgical treatments) and recommend an appropriate postoperative follow-up since synchronous or metachronous bowel carcinomas are likely to occur.

[Th1-Th2 cytokine correlates (INF-gamma and IL-4) in splenectomized patients]. / Studio delle citochine Th1-Th2 correlate (IFN gamma e IL-4) negli splenectomizzati.

This paper attempts to explain if immunodepression in patients who had undergone a splenectomy may be due to altered balance between Th1-Th2 lymphocyte subpopulations, as shown in several studies on phagocyte and lymphocyte cells. This was achieved by dosing serum levels of IFNg, produced by Th1 lymphocytes and IL-4, produced by Th2 lymphocytes. Final analysis showed immunodepression in splenectomized patients but also emphasized that in 70% of all cases, there is functional damage of T-lymphocytes that continues for several years after the surgery involving both cellular and humoral immunity. Immunoglobulin dosage allows the increase of IgE to be seen in 50% of the splenectomized patients studied, all with allergic symptoms that appeared after the operation. The production of IgE is stimulated by Th2 lymphocytes. This leaves one to believe that splenectomy may favour the persistence of allergens in the blood, the appearance of allergic symptoms and the increase of IgE serum levels in patients with normal Th2 functioning and consequently, with normal or increased IL-4 serum levels.

[The dehiscence of colorectal anastomoses: the risk factors]. / Le deiscenze nelle anastomosi colo-rettali: fattori di rischio.

OBJECTIVE: To evaluate the results of emergency and elective colorectal resective surgery; to identify general and local factors that influence the anastomotic leak rate. MATERIAL AND METHOD: 200 selected consecutive patients (115 males and 85 females, medium age 50.6 years, range 16-87) underwent resective colorectal surgery between 1990 to 1997. 154 (77.0%) were operated in elective surgery and 46 (23.0%) in urgency, for carcinoma, diverticular disease, mesenteric infarction, chronic intestinal disease, dolicosigma, anastomotic leakage, familiar polyposis or lesions by firearm. The operations consisted in 58 right colectomy, 28 left colectomy, 6 resection of the transverse and 29 of the sigmoid colon, 40 anterior resection, 12 total colectomy, 19 closing of colostomy, 6 by-passes. Anastomoses were performed in 88 cases by manual and in 110 by mechanical sutures. RESULTS: We observed 12 (6%) anastomotic leakages. Mortality rate was 1.0%. 13%.0 of these patients were underwent before to emergency and 3.9% to elective surgery; 5.7% by manual and 6.4% by mechanical suture. Diagnosis of leakage was made by clinical features, blood vessel examinations and abdominal TC scan. DISCUSSION: The risk factors of anastomotic leakage are general or local. Chronic obstructive pulmonary disease, perioperative transfusion, level of serum albumin, use of corticosteroid in the first group and sepsis, bowel obstruction, anastomotic level and tension and poor blood supply in the second, appear the most important causative factors in the development of anastomotic leaks. CONCLUSION: The incidence of dehiscence in colo-rectal surgery was seen significatively lower when anastomoses were performed in ideal circumstances than in the presence of one or more unfavorable factors. Healing remains a process depending more on the patient than on any aspect of the surgical technique.

[Our directions for the treatment of colorectal cancer]. / Nostri indirizzi nel trattamento del cancro colo-rettale.

Authors make a review of personal experience in colorectal surgery from 1998 to 1997 (18 year) and indicate the own opinion about oncological principle of colorectal surgery. Colo-rectal cancer is the most frequent tumor in West Countries (United States 156,000 new case/year, Europe 58,300 deaths/year). A Medline analysis using terms "colon and rectal cancer" prove a progressive increasing of interest about many problems regard prevention, diagnosis, prognosis and therapy of colorectal cancer. Prognosis of colorectal cancer depend on correct and complete stadiation. The most used classifications are Dukes classification, modified from Astler-Coller, and TNM classification of UICC. In the past years oncologic al principle of colorectal surgery was modified from a new debated concept of oncological radicality. The authors analyze own experience in comparison to Literature about the "no touch isolation technique", the principle of vascular ligation at the origin of vessels, lymphectomy extension, total mesorectal excision, surgical decision about advanced loco-regional cancer, surgical decision of complicated colorectal cancer (perforation and occlusion), the role of bilateral prophylactic ovariectomy, surgical treatment of liver metastasis, correct indication of T.E.M. and finally the role of laparoscopic surgery for the treatment of colorectal cancer.

[Palliative treatments in obstructive jaundice due to periampullary neoplasms]. / I trattamenti palliativi dell'ittero ostruttivo da neoplasie periampollari.

OBJECTIVE: The evaluation of the palliative procedures, surgical and endoscopical or radiological, in the treatment of patients affected by obstructive jaundice resulting from periampullary tumors. SUBJECTS: Patients with jaundice by periampullary tumors undergoing to surgery or to endoscopical or radiological procedures from january 1987 to april 1998. RESULTS: Jaundice has come down in all patients after surgery. Mortality after surgery was 5.2% (5.9% in geriatric patients); morbidity 15.8% (17.6% in geriatric patients) survival 10.4 months after surgery (8.8 months in geriatric patients) versus 3.1 months after non surgical procedures. DISCUSSION: In all patients periampullary tumors are more frequent than hepatic hilum and common bile duct tumors. We have performed surgical and not surgical palliative procedures more frequently than curative resection (DCP), especially in geriatric patients (94.5% versus 79%). In geriatric patients we have chosen, between bile-digestive by-passes, the cholecysto-jejunal anastomosis because it is easier and faster to carry out than choledochojejunal anastomosis with the same results as well as from literature data. We have always performed a gastroenteric anastomosis in association with palliative surgical procedures to prevent or to solve a duodenal obstruction. This additional treatment didn't show an increasing of mortality and morbidity as well as from literature data. CONCLUSIONS: We have reserved the palliative non surgical procedures only to high surgical risk patients. In the other cases we have chosen palliative surgery for better long-term results and quality of life in the general series patients as well as in geriatric patients.

[Correlation between chronic obstructive bronchial disease and colonic anastomosis dehiscence in the elderly]. / Correlazioni tra broncopatia cronica ostruttiva e deiscenza dell'anastomosi colica in età geriatrica.

BACKGROUND: Anastomotic leakage remains a major complication after large bowel surgery. Chronic obstructive pulmonary disease is frequent disease in the elderly. AIMS: The authors want to analyze the correlation between systemic tissue hypoxia, resulting from chronic obstructive pulmonary disease and anastomotic leakage in large bowel surgery in a group of patients over 65 years. PATIENTS AND METHODS: In the period 1979-2001 at our surgical Department, 590 patients underwent colorectal surgery; 211 elderly patients (> 65 years) with large bowel anastomosis were selected. In 29/211 (13.7%) chronic obstructive pulmonary disease was diagnosed. The group of patients affected by chronic obstructive pulmonary disease was defined as group A; the other, as group B. The incidence of anastomotic leakage in patients with and without chronic obstructive pulmonary disease was evaluated. RESULTS: The overall incidence of anastomotic leakage was 5.6% (12/211); a difference in the incidence of anastomotic leakage was found in the group A vs. B: 7/29 (24.1 %) in the group A were affected by dehiscence vs. 5/182 (2.7%) of group B. This difference was statistically significant (p = 0.001). CONCLUSIONS: Chronic obstructive pulmonary disease can be a factor increasing the risk of anastomotic leakage. The elderly patient is often affected by chronic obstructive pulmonary disease and consequently show an higher risk of colonic anastomotic failure than younger patients.

[The role of palliation in peri-ampullar tumors in the elderly]. / Il ruolo della palliazione nei tumori periampollari in età geriatrica.

Authors wonder about the actual part of the palliative practices in periampullar cancers of the geriatric age, and the choice criteria of the different surgical options that are practicable. They reaffirm that the common radical operation is the pancreaticoduodenectomy, even if, as it is verifiable in the relevant literature and in our series of cases, it is practicable only a few times. The necessity of amending the toxic-septic condition of the neoplastic cholestasis, which certainly is more unfavourable during the geriatric age, gives to the palliative procedures a better role, because few patients could be treated with a curative intention. Authors report their experience and their results about the icterus regression, mortality, morbidity and the average survival rate. About the surgical palliative options of the bilio-digestive shunts, they give the same importance to the gallbladder jejunostomy and to the common bile duct jejunostomy, granting to the first their preference in the geriatric age for the simplest and rapid execution. They point out the necessity of the gastrojejunostomy in all the present or incipient jejuno's obstruction, because of the surgical action importance, and to avoid another operation. They give, even in the geriatric age, their preference to the surgical palliative treatments, proposing to reserve the endoscopic and radiologic practices to the patient undergoing an operation for the precarious general state, for the high operating risk and the modest residual life. In fact, the non surgical treatments are suitable to amend the neoplastic cholestasis, but they aren't equivalent to the surgical palliative, that is more effective for the greater survivals, a better life's quality, a smaller mortality and morbidity.

[Primary non-Hodgkin's lymphoma of the stomach (a rare case of extensive spread to the entire organ)]. / Linfoma non-Hodgkin primitivo dello stomaco (su un raro caso di estesa diffusione all'intero viscere).

Primary gastric lymphoma is the most frequent extra nodal primary site for non-Hodgkin's lymphoma (NHL) and is itself uncommon. Moreover, a massive infiltration of all stomach (from cardias to antrum) simulating a linitis plastica, it's rare. We present a case report of this atypical presentation of primary gastric NHL in a 73 year old females. The patient came to our observation complaining of dyspepsia, epigastric pain and vomiting from 7 months associated with weight loss and asthenia. Physical examination revealed an epigastric palpable mass. Computed tomographic findings has been necessary to confirm that the massive infiltration of gastric wall (from cardias to pylorus) was ascribed to lymphoma. Dawson's criteria was respected to define primary gastric NHL and was performed a total gastrectomy with systematic lymphadenectomy. The histopathological evidences have confirmed clinical diagnosis of primary gastric NHL. Preoperative diagnosis to clarify the nature of lesions (primary or not) and accurate staging of neoplasm before the operation are indispensable for a correct therapeutic approach; in according to the Ann Arbor classification modified by Musshoff our cases was stage IIE and radical gastrectomy with systematic lymphadenectomy was performed. Surgical resection is generally considered to have a definitive role in the treatment of primary gastric lymphoma specially for the stage IE and IIE.

[Obstructive jaundice caused by hydatid cyst rupture in main bile duct]. / Ittero ostruttivo da rottura di cisti idatidea nella via biliare principale.

Hydatid hepatic cyst rupture into bile duct is a complication of hydatid disease. The rupture is more frequent in right or left epatic duct and occasionally in common bile duct (7-9%). A 50-year old man came to emergency room owing to jaundice, fever and abdominal pain. TC show an hydatid cyst with daughter's cyst of left liver and dilatation of biliary tree. Laboratory data of significance included an increased of liver function tests (Bilirubin, Alkaline ph., SGOT, SGPT), VES and leukocytosis. The patients was surgically treated, by total pericystectomy, colecystectomy and coledocotomy with lavage o common bile duct; finally we placed one Kehr drainage and two abdominal drainage. After 15 days of postoperative hospitalization patient was discharged. The best treatment of hydatid cyst is total pericystectomy (when possible). An alternative surgical treatment is possible for the presence of communication with biliary tree. ERCP is very important for a correct diagnosis and for a complete surgical treatment.

[Right abdominal colonic masses. Recent diagnostic and therapeutic advances: personal experience]. / Masse addominali destre di appartenenza colica. Recenti acquisizioni diagnostiche e terapeutiche: esperienza personale.

The authors, referring to their experience, make a review of colic pathological features presenting as right abdominal mass. Despite of modern diagnostic means--specially radiological investigations: ultrasonographic and CT scanning--accurate clinical examination still plays a role in the initial assessment and to address diagnostic procedures. Diagnosis may be difficult as the right colon is hardly accessible even to present investigative means. US scanning has proved to be useful, in the surgeon's hands, for timely detection of the lesion and in monitoring its evolution. Many diseases must be considered in the diagnosis of a right colon mass and a few rare too: Meckel diverticolitis, carcinoid, vermiform appendix pseudomyxoma, amebic granuloma, Kaposi's sarcoma. Treatment is still an intriguing question, depending on many factors: site, kind and variety of the diseases showing as right abdomen mass, difficulty in early diagnosis, risk of misdiagnosing, shortage of series reported in literature and the absence of multicenter studies.

[Hepatic hydatidosis in Puglia: analysis of the hospital discharge cards in the years 1996-2000]. / L'echinococcosi epatica in Puglia: analisi delle schede di dimissione ospedaliera (S.D.O.) negli anni 1996-2000.

The authors valueted the distribution of Hepatic Hydatidosis in the Region Puglia (Italy) by hospital dimission cards (schede di dimissione ospedaliera). At present, the SDO represent the most important information tool to monitor hospital activity. The authors examined 468 cases of hepatic Hydatidosis admitted in regional hospital during 1996-2000. 54% were men and 46% women, 75% of whom aged between 40-60 anni. The median hospitalization time was of 12 days and 80% were surgical departments. All the cases examined were uniformedly distributed in surgical hospitals. No hospital acts as a pole of attraction. The periodal prevalence was 6.4/100.000. 40% of cases had surgical DRG with quadriennal sanitary cost of 4 miliardi liras. The Surgical procedure was 53% hepatic lesion demolition, 14% partial epatectomy, 7.2% lobectomy, 5.2% marsupializzazione, 2.6% hepatectomy, and 19% others procedures. At present, due to physiopathological considerations, radical surgery is preferred to conservative surgery. Hepatic hydatidosis is considered a public health problem whose epidemiologic monitoring and precautionary measures could be oriented to control the related sanitary costs.

[Urgent ulcerative colitis: our experience]. / Rettocolite ulcerosa in urgenza ed emergenza: nostra esperienza.

The authors refer their experience in Urgent Ulcerative Colitis. They define the various clinical maniferstations and then specify the necessary elements for a corrent nosological arrangement. About diagnosis, their confirm the inconvenience of clinical examination like as colonscopy or an opaque clysma, giving their choice to other parameters, like as clinical, hematic (PCR), microscopic and cultural of the faeces, radiological (direct abdomen radiography; abdomino-pelvic echography; abdomino-pelvic TC, better if spiral), endoscopic (rectoscopy with minimal insufflation). They explain their guideline about medical therapy, the strategy adopted in relation to its duration, the protocol of evaluation during the administration period and the predictive sighs of its possible failure. After having precised the surgical indications, they stop a little about the timing of a surgical interventation, underlining its primary importance. In the range of a surgical strategy. They give their choice to the total colectomy with associated ioleostomy for its less incidence of complications and mortality versus proctocolectomy, reserving this last one to that cases with irreprensible rectal hemorragy, with preservation of the anal canal for a possible delayed ileo-anal anastomosis. They also think, at last, that after an Urgent Total Colectomy, the immediate ileo-rectum anastomosis could have an high risk of dehiscence of the anastomosis itself and so it must be reserved only to that selected cases which offer local and general guarantees of solidity of the anastomosis and it must be preferably done joinly whit a loop ileostomy at the bottom of the anastomosis itself.