The immunocompromised host: immune alterations in splenectomized patients and clinical implications.

The spleen plays a paramount role in the host protection against invading microorganisms. In support of the above concept, in splenectomized patients there is increasing evidence of overwhelming postsplenectomy infections (OPSI). OPSI are caused by Streptococcus pneumoniae in about 80% of cases, but also Gram-negative bacteria are implicated in a certain number of cases. Therapeutically, penicillin and pneumococcal vaccines represent valid therapeutic approaches in Gram-positive OPSI. However, the effectiveness of polyvalent polysaccharide pneumococcal vaccines is still debated and, thus, other therapeutic strategies should be validated for combating OPSI. According to our personal data, a deficit of phagocytic activities and of T helper (h)-1 cells is very frequent in splenectomized patients. In sera, we found reduced levels of both Interferon-gamma and Interleukin (IL)-4. These data are in accordance with the recent observation on the protective role of T cells against S. pneumoniae. In fact, patients deficient in IL-12 develop severe pneumococcal infections and undergo apoptosis of Th(1) cells.

Late appearance of acanthocytes during the course of chorea-acanthocytosis.

A case of chorea-acanthocytosis (CA) syndrome is described. The presence of acanthocytes has usually been considered an important diagnostic marker of CA. However, it is not specific and other neurological diseases have to be considered. In the present report we rule out other diagnostic possibilities and show that the acanthocytes in the peripheral blood smears can appear even later during the course of the disease.

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.

Microsurgical treatment of varicocele in outpatients using the subinguinal approach.

BACKGROUND: The aim of this study is to analyze the results of a group of patients who underwent subinguinal microsurgical varicocelectomy using local anaesthesia in one-day-surgery. METHODS: From 1997 to 1998 150 patients were selected from the whole group of patients who underwent surgical treatment for varicocele. The varicocele was always on the left side and the mean age was 27.1 years (range: 16-43). The diagnosis was based on clinical features (testicular pain or scrotal sensation), physical examination and Doppler ultrasound. Where there was infertility with abnormal semen analysis and/or patient's intolerance to the symptoms, surgery was suggested. The patients underwent varicocelectomy by sub-inguinal approach using local anaesthesia. The microsurgical technique of dissection was performed. RESULTS: All operations were performed on an outpatient basis (post-operative stay: 3-7 hours) and the operating time was 20 to 45 minutes. Follow-up was performed by physical examination, doppler ultrasound and semen analysis. Immediate and long-term complications were: 7 (4.7%) transient pain, 3 (2.0%) ecchymosis, 1 (0.7%) transient hydroceles and 1 (0.7%) permanent hydroceles, 2 (1.3%) palpable recurrence, 2(1.3%) doppler recurrence and 1 (0.7%) long-term recurrence, 0 testicular atrophy. 120/150 (80%) patients showed an improvement of semen analysis and 19/41 (46.3%) patients with infertility achieved a pregnancy with the partner. CONCLUSIONS: Microsurgical treatment of varicocele in outpatients by subinguinal approach is a safe and reliable procedure. It is performed in local anaesthesia, preserves the lymphatics, spermatic artery and vas and in our experience showed an improvement of semen analysis and pregnancy rates with minimal morbidity.

[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.

[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.

[Acute pancreatic necrosis complicated by infection and gastro-intestinal translocation: pathogenesis correlation and therapeutic implication]. / Necrosi pancreatica acuta infetta e translocazione batterica intestinale: correlazioni patogenetiche e implicazioni terapeutiche.

The authors define pathogenetics correlations as a acute necrotizing pancreatitis complicated by infection and bacterial translocation. Acute necrotizing pancreatitis infection occurs for gastrointestinal bacterial translocation due to structural and functional modifications of intestinal mucosa. These modifications are results of mucosa ischemic-reperfusion system caused by systemic emodynamic instability in micro- and macro-circulation of splanchnic district. Emodynamic systemic instability has a central role in different multiple physiopathologic phenomena (ipovolemic shock; pancreatic shock, SIRS), which is caused by acute pancreatic necrosis and carries to common way established by severe systemics emodinamics modifications; these changes promote growth of adverse events which conduce by means of process previously described to bacterial translocation and infection of acute pancreatic necrosis. Indeed, emodynamic systemic instability of any etiology, can determine for one way bacterial translocation and on the other acute ischemic pancreatitis; both phenomena concur lead to cause beginning of acute necrotizing pancreatitis complicated by infection. The authors confirm that improved knowledge of acute pancreatic necrosis complicated by infection and own pathogenetic correlations with bacterial translocation, allows the realization of therapeutic measures aimed to prophylaxis of infection of acute pancreatic necrosis. Central emodynamic stability regularization of splanchnic perfusion and antibiotic prophylaxis, have a central role in prophylaxis of infection of acute pancreatic necrosis. Antibiotic is given by systemic (imipenem e.v.) and selective decontamination of gastrointestinal tract (SDD). SDD provides for oral antibiotic prophylaxis (PTA protocol) and systemic antibiotic prophylaxis (cefotaxime and gentamicin), in addition to microbiologic and gastrointestinal monitoring. If on the one hand the role of SDD about mortality reduction is not clear, however, on the other it is well recognized capacity of reduction the intercurrents and pulmonary infections. Other Authors think that SDD is insignificant on early mortality, whereas, is a good option to reduce late and overall mortality of acute pancreatic necrosis complicated by infection.

Perineal pilonidal sinus. Case report.

Pilonidal sinus is a very common disease and its most frequent location is in the presacral area. Other locations are extremely rare. We describe the case of a 28-year-old white man, a baker by profession, with a swelling around the right side of the anus, pain with burning, itching and seropurulent secretion which had been present for 7 months. A physical examination demonstrated the presence of multiple cutaneous fistulas. A fistulography and the endoscopy demonstrated the absence of fistulas-in-ano. Moreover, MRI confirmed the diagnosis of a perianal mass not communicating with the anal canal. Surgical exploration revealed the presence of hair and an excision of the mass with fistulas was performed. Healing was rapid and uncomplicated. Perineal pilonidal sinus with foreign body inflammatory reaction was the histological diagnosis.

[Coagulation disorders following severe trauma: surgeon's role in prevention]. / Turbe della coagulazione nel trauma severo: il ruolo del chirurgo nella prevenzione.

INTRODUCTION: Severe trauma must be considered a "systemic disease" that could lead to severe systemic complications. PHYSIOPATHOLOGIC IMPLICATIONS: Coagulation disorders are present in most trauma patients as hemorrhagic disorder, thrombosis, or like in DIC, with both coexistent phenomenon. Trauma determine the activations of intrinsic and extrinsic coagulation pathways, and of platelets. Intrinsic pathway activation induce a pro-coagulant function and the activation of fibrinolytic system. Both system activation explain low incidence of deep venous thrombosis. Post-traumatic activation of extrinsic coagulation lead to thrombin and fibrin production. In trauma patients platelets activation is related to endothelial damage, exposition of collagen, interaction with PAF and presence of microorganisms. Post-traumatic DIC is characterized by procoagulant factors activation, with intravascular deposit of fibrin and thrombosis, and by hemorrhagic disorders due to consumption of platelet and procoagulant factors. Lower levels of antithrombin III, in trauma patients, are strictly related to severity of damage and shock. Coagulation disorders related to sepsis, that often complicate trauma, are added to those determined by trauma, with a negative synergic effect. Medical treatment with massive infusion of colloid and crystalloid solution, and fluid, and massive transfusion of plasma and red blood cells can determine dilutional thrombocytopenia, reduced activity of coagulation factors and reduced haemostatic activity of RBC due to excessive haemodilution--Hct <20%. PREVENTION STRATEGY: To avoid post-traumatic coagulation disorders is important to prevent sepsis, thrombocytopenia and reduced activity of coagulation factors and of RBC, as well as prevent and immediately treat shock. The early use of high dose antithrombin concentrate, is important to prevent DIC and MOFS, and administer subcutaneous or intravenous heparin, in absence of hemorrhagic disorders that contraindicate its use.

[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.

[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.

[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.

[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.

[Immunological implications of surgical intervention in critical and noncritical patients]. / Implicazioni immunologiche dell'intervento chirurgico nel paziente critico e non.

Immunological implications are important in every surgical operation, specially when it is necessary to remove the spleen. She plays an important role in immunological aspecific (filter, phagocytosis) and specific processes (production of IgM and regulation of T- and B-lymphocytic system). Splenectomy causes an immunodeficiency with frequent post-operative complications (the most important is OPSI). Each operated patient is considered generically immunodeficient because surgical trauma and anesthesiologic practice are at the base of immunological alterations (biological barriers, aspecific immunity, A.P.P., complement, specific immunity, NK cells). It's indispensable to know pathological situations that make "critical" the immunological state: caloric-proteic malnutrition, elderly (greater than 70 years old), immunosuppressive therapy, sepsis, shock, neoplasms. I. e.: a patient about seventy years old presents a reduced endocrine secretion of thymic hormone and, probably, a low synthesis of immunoglobulins. Besides the corticosteroids modify the answer of T-lymphocytes and NK cells. Sepsis induces metabolic and immunological alterations after early activation of humoral mediators, modified quantity and life of A.P.P., activation of complement, inhibition of cell-mediate immunity, modification of number and activity of haematic lymphocytes. Trauma induces a hypersecretion of corticosteroid, adrenalin, noradrenaline, glucagon with consequent hypercatabolism that causes malnutrition. The hormonal hypersecretion is a determining factor of reduced phagocytic activity (inhibited migration of neutrophils and monocytes), quantitative and qualitative alterations of complement, deficit of T-cells, hyporeactivity to skin test, depressed answer of antibodies to bacterial and viral antigens. Progressive neoplasms are characterized by modification of T-lymphocytes number, depressed macrophagic activity, hyporeactivity to skin tests.

Bridges between nervous and immune systems: their disconnection and clinical consequences.

Nervous and immune systems are connected by several mutual links, thus constituting a diffuse functional network in the body. In particular, neurohormones, neuropeptides, and cytokines represent the major mediators of the so-called psychoneuroendocrinoimmune axis. In this review, special emphasis is placed on certain pathologies characterized by a disconnection of the existing bridges between nervous and immune systems. For instance, spinal cord injury (SCI) is a clinical condition in which loss of neurons and very poor axon growth represent the main features. The role played by infiltrating and resident immunocompetent cells is still debated in SCI. However, to enhance axon growth in SCI, current therapeutic attempts are based on the stimulation of the immune response within the central nervous system, thus triggering either cell-mediated or humoral immune responsiveness.

Splenectomy and sepsis: the role of the spleen in the immune-mediated bacterial clearance.

Over the past few years, many observations of overwhelming post splenectomy bacterial infections have been reported. Streptococcus pneumoniae is the aetiologic agent in about 80% of cases, but also gram-negative bacteria are involved in the development of fatal infections in splenectomized patients. Functionally, the spleen plays a fundamental role in bacterial clearance either by antibody response or macrophage bactericidal capacity. At the same time, there is evidence that the spleen also contributes to bacterial endotoxin detoxification. Finally, the mechanisms responsible for gram-positive and gram-negative sepsis in the splenectomized host and possible therapeutical approaches able to neutralize bacterial products endowed with noxious effects are discussed.