The treatment of anal fistulas with biologically derived products: is innovation better than conventional surgical treatment? An update.

New technical approaches involving biologically derived products have been applied in the treatment for anal fistulas in order to avoid the risk of fecal incontinence. The aim of this review was to evaluate the scientific evidence present in the literature regarding these techniques. Trials comparing surgery (fistulotomy, advancement mucosal flap closure and placement of seton) versus fibrin glue, fistula plug or acellular dermal matrix were considered. In fibrin glue versus traditional surgical treatment the healing rate was higher in the surgery group, and the recurrence rate was lower in the traditional surgery group, but these results were not statistically relevant. In acellular dermal matrix (ADM) versus traditional surgical treatment the recurrence rate of fistulas was significantly lower in the ADM group, but non-significant differences were recorded in incontinence and anal deformity. Our review shows that there are no significant advantages of the new techniques involving biologically derived products. Further randomized controlled trials are needed.

Ghost Ileostomy with or without abdominal parietal split.

BACKGROUND: In patients who undergo low anterior rectal resection, the fashioning of a covering stoma (CS) is still controversial. In fact, a covering stoma (ileostomy or colostomy) is worsened by major complications related to the procedure, longer recovery time, necessity of a re-intervention under general anesthesia for stoma closure and poorer quality of life. The advantage of Ghost Ileostomy (GI) is that an ileostomy can be performed only when there is clinical evidence of anastomotic leakage, without performing further interventions with related complications when anastomotic leak is absent and therefore the procedure is not necessary. Moreover, in case of anastomotic dehiscence and necessity of delayed stoma opening, mortality and morbidity in patients with GI are comparable with the ones that occur in patients which had a classic covering stoma. On the other hand, is simple to think about the possible economic saving: avoiding an admission for performing the closure of the ileostomy, with all the costs connected (OR, hospitalization, post-operative period, treatment of possible complications) represents a huge saving for the hospital management and also raise the quality of life of the patients. METHODS: In this study we prospectively analyzed 20 patients who underwent anterior extra-peritoneal rectum resection for rectal carcinoma with TME and fashioning of GI realized with or without abdominal parietal split. RESULTS: In the group of patients that received a GI without split laparotomy mortality was absent and in one case an anastomotic leak occurred. In the group of patients in which GI with split laparotomy was fashioned, one death occurred and there were one case of infection and one respiratory complication. Clinical follow-up was 12 months. CONCLUSIONS: The use of different techniques for fashioning a GI do not present significant differences when they are performed by expert surgeons, but further evidence is needed with more randomized trials, in order to have more data supporting the clinical observation.

Ghost ileostomy after anterior resection for rectal cancer: a preliminary experience.

PURPOSE: The aim of this study was to describe and evaluate the feasibility and the eventual advantages of ghost ileostomy (GI) versus covering stoma (CS) in terms of complications, hospital stay and quality of life of patients and their caregivers after anterior resection for rectal cancer. METHODS: In this prospective study, we included patients who had rectal cancer treated with laparotomic anterior resection and confectioning a stoma (GI or CS), in the period comprised between January 2008 and January 2009. Short-term and long-term surgery-related mortality and morbidity after primary surgery (including that stoma-related and colorectal anastomosis-related) and consequent to the intervention of intestinal recanalization (CS group) and GI closure were evaluated. We evaluated hospital stay and quality of life of patients and their caregivers. RESULTS: Stoma-related morbidity rate was higher in the CS group than in GI group (37% vs. 5.5%, respectively, P = 0.04). Morbidity rate after intestinal recanalization in the CS group was 25.9% and 0% after GI closure (P = 0.08). Overall stoma morbidity rate was significantly lower in the GI group with respect to CS group (5.5% vs. 40.7%, respectively, P = 0.03). CS group was characterized by a significantly longer recovery time (P = 0.0002). Caregivers and stoma-related quality of life were better in the GI group than in CS group (P < 0.0001 and P = 0.0005, respectively). CONCLUSIONS: GI is feasible, characterized by shorter recovery, lesser degree of total, as well as anastomosis-related morbidity and higher quality of life of patients and the caregivers in respect to CS. We suggest that GI (should be evaluated as an alternative to conventional ileostomy) could be indicated in selected patients that do not present risk factors, but require caution for anastomotic leakage for the low level of colorectal anastomosis.

The sigmoid volvulus: surgical timing and mortality for different clinical types.

BACKGROUND: In western countries intestinal obstruction caused by sigmoid volvulus is rare and its mortality remains significant in patients with late diagnosis. The aim of this work is to assess what is the correct surgical timing and how the prognosis changes for the different clinical types. METHODS: We realized a retrospective clinical study including all the patients treated for sigmoid volvulus in the Department of General Surgery, St Maria Hospital, Terni, from January 1996 till January 2009. We selected 23 patients and divided them in 2 groups on the basis of the clinical onset: patients with clear clinical signs of obstruction and patients with subocclusive symptoms. We focused on 30-day postoperative mortality in relation to the surgical timing and procedure performed for each group. RESULTS: In the obstruction group mortality rate was 44% and it concerned only the patients who had clinical signs and symptoms of peritonitis and that were treated with a sigmoid resection (57%). Conversely none of the patients treated with intestinal derotation and colopexy died. In the subocclusive group mortality was 35% and it increased up to 50% in those patients with a late diagnosis who underwent a sigmoid resection. CONCLUSIONS: The mortality of patients affected by sigmoid volvulus is related to the disease stage, prompt surgical timing, functional status of the patient and his collaboration with the clinicians in the pre-operative decision making process. Mortality is higher in both obstructed patients with generalized peritonitis and patients affected by subocclusion with late diagnosis and surgical treatment; in both scenarios a Hartmann's procedure is the proper operation to be considered.

A severe case of hemobilia and biliary fistula following an open urgent cholecystectomy.

BACKGROUND: Cholecystectomy has been the treatment of choice for symptomatic gallstones, but remains the greatest source of post-operative biliary injuries. Laparoscopic approach has been recently preferred because of short hospitalisation and low morbidity but has an higher incidence of biliary leakages and bile duct injuries than open one due to a technical error or misinterpretation of the anatomy. Even open cholecystectomy presents a small number of complications especially if it was performed in urgency. Hemobilia is one of the most common cause of upper gastrointestinal bleeding from the biliary ducts into the gastrointestinal tract due to trauma, advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage. METHODS: We report here a case of massive hemobilia in a 60-year-old man who underwent an urgent open cholecystectomy and a subsequent placement of a transhepatic biliary drainage. CONCLUSION: The management of these complications enclose endoscopic, percutaneous and surgical therapies. After a diagnosis of biliary fistula, it's most important to assess the adequacy of bile drainage to determine a controlled fistula and to avoid bile collection and peritonitis. Transarterial embolization is the first line of intervention to stop hemobilia while surgical intervention should be considered if embolization fails or is contraindicated.

Gastric adenocarcinoma cutaneous metastasis arising at a previous surgical drain site: a case report.

INTRODUCTION: Skin metastasis from internal carcinoma rarely occurs. It has an incidence of 0.7 to 9% and it may be the first sign of an unknown malignancy. However, it can also occur during follow-up. CASE PRESENTATION: A 90-year-old female patient was admitted to our surgical division with a diagnosis of anemia from a bleeding gastric adenocarcinoma. She underwent a gastric resection and Billroth II retrocolic Hofmeister/Finsterer reconstruction. She developed an enteric fistula, which needed a permanent abdominal drain until the 60th postoperative day. After 12 months she was readmitted to our division with subacute small bowel obstruction and an erythematous swelling on the right side of the abdomen. Biopsies characterized it as a cutaneous metastasis from the gastric adenocarcinoma. No surgical therapy was performed given her poor clinical condition. CONCLUSION: Skin metastasis from carcinomas of the upper gastrointestinal tract is very rare. Persisting erythematous nodules must be biopsied in order to diagnose cutaneous metastases and to recognize them early and start prompt therapy with anti-tumour agents before the occurrence of massive visceral metastases.

Feasibility of laparoscopy for small bowel obstruction.

BACKGROUND: Adherential pathology is the most common cause of small bowel obstruction. Laparoscopy in small bowel obstruction does not have a clear role yet; surely it doesn't always represent only a therapeutic act, but it is always a diagnostic act, which doesn't interfere with abdominal wall integrity. METHODS: We performed a review without any language restrictions considering international literature indexed from 1980 to 2007 in Medline, Embase and Cochrane Library. We analyzed the reference lists of the key manuscripts. We also added a review based on international non-indexed sources. RESULTS: The feasibility of diagnostic laparoscopy is high (60-100%), while that of therapeutic laparoscopy is low (40-88%). The frequency of laparotomic conversions is variable ranging from 0 to 52%, depending on patient selection and surgical skill. The first cause of laparotomic conversion is a difficult exposition and treatment of band adhesions. The incidence of laparotomic conversions is major in patients with anterior peritoneal band adhesions. Other main causes for laparotomic conversion are the presence of bowel necrosis and accidental enterotomies. The predictive factors for successful laparoscopic adhesiolysis are: number of previous laparotomies

[Virtual colonoscopy in stenosing colorectal cancer]. / Colonscopia virtuale nelle neoplasie stenosanti del colon-retto.

In 5-10% of patients it is not possible to achieve a complete endoscopic examination of the colon, because of obstructing cancer, excessive length of the colon, anatomical abnormalities or adhesions. Virtual colonoscopy is currently capable of investigating the colic lumen with a non-invasive technique, with high specificity and sensitivity. From January 2005 to July 2007 we treated 21 patients with obstructing neoplastic colorectal lesions, preventing a complete endoscopic examination. In all patients we performed a virtual colonoscopy, which revealed the presence of synchronous lesions (19%): a pedunculated polyp in two cases, a sessile polyp in one case and a right colonic vegetating lesion. In the 21 patients studied we performed a follow-up colonoscopy 3 months after the surgical treatment. No other endoluminal lesions were found, confirming the results of virtual colonoscopy. In our experience virtual colonoscopy presented 100% sensitivity and specificity. In this selected group of patients with obstructing lesions of the colon, virtual colonoscopy enables the surgeon to evaluate the entire colon, avoiding the execution of an intraoperative colonoscopy and possible surgical reintervention due to the finding of synchronous neoplastic lesions at postoperative follow-up endoscopy.

[Minimally invasive treatment of synchronous colorectal tumours]. / Trattamento mini-invasivo delle neoplasie sincrone del colon-retto.

In patients with colorectal cancers synchronous neoplastic lesions are an increasingly frequent finding at preoperative staging; 3% of the cases are other cancers while 33-35% of the synchronous lesions are villous adenomas. The treatment of most colorectal adenomas can be performed by endoscopic poplypectomy. In 5% of cases there are synchronous colorectal lesions also requiring surgical treatment. From January 1995 to June 2007 we treated 5 patients with rectal lesions by transanal endoscopic microsurgery (TEM) together with a laparoscopic colectomy for the presence of synchronous lesions at the "Clinica Chirurgica Generale e d'Urgenza" of the University of Perugia,. Surgical timing involved performing a sequential exeresis characterised by a cancer resection, followed by resection of the voluminous adenoma: TEM for rectal cancer followed by a laparoscopic right hemicolectomy with an extracorporeal anastomosis for a voluminous villous adenoma (1 patient) and laparoscopic right hemicolectomy with an extracorporeal anastomosis for cancer followed by TEM for a voluminous villous adenoma (2 patients). One patient with left colon cancer associated with a voluminous villous rectal adenoma first underwent TEM for the rectal adenoma and then a left laparoscopic hemicolectomy with an extracorporeal anastomosis in order to ease the transit of the circular mechanical stapler. Another patient with rectal and right colon adenomas first underwent TEM for a voluminous rectal sessile adenoma and later a right hemicolectomy. The use of this minimally invasive approach allowed rectum preservation and less invasive surgery.

Minimally invasive sacral neuromodulation implant technique: modifications to the conventional procedure.

PURPOSE: Sacral neuromodulation is a novel treatment for selected urinary and bowel dysfunctions. A new method is described for electrode implantation, the "minimally invasive sacral neuromodulation implant technique." METHODS: After the percutaneous nerve evaluation test, a small longitudinal incision (3 cm) is made, and a catheter cannula segment is inserted through the sacral foramen beside an insulated needle. The electrode is introduced into the catheter cannula, which is then removed and fixed to the sacrum by means of small anchors. The proximal part of the lead is tunneled into the subcutaneous tissue, reaching the pocket made to accommodate the neurostimulator. RESULTS: This procedure was performed in ten patients (5 male; mean age, 50.4 years). In four patients a single electrode was implanted, and in six patients two electrodes were implanted. The minimally invasive technique was significantly faster, saving a mean time of 20 minutes for each electrode. The incision made directly on the sacral foramen was significantly reduced (3 vs. 12 cm), avoiding the wide, blunt dissection of subcutaneous fat tissue. Application of the catheter cannula allowed the electrode to be introduced easily and correctly. The electrode anchors never failed: no cases of lead displacement or suboptimal position of the electrode occurred. A unilateral, sterile subcutaneous seroma occurred in one of the ten patients. CONCLUSIONS: The minimally invasive sacral neuromodulation implant technique seems to be a safe procedure-making sacral neuromodulation implant easier, faster, and safer, in as much as complications could be potentially reduced.