A narrative review of the impact of surgery and anaesthesia on acute kidney injury.

The epidemiology of peri-operative acute kidney injury varies depending on the definition, type of surgery and acute and chronic comorbidities. Haemodynamic instability, disturbance of the microcirculation, endothelial dysfunction, inflammation and tubular cell injury are the main factors contributing to the pathogenesis. There are no specific therapies. The most effective strategies to protect renal function during the peri-operative period are: the avoidance of nephrotoxic insults; optimisation of haemodynamics; prevention of hypotension; and meticulous fluid management, including avoidance of both hypovolaemia and hypervolaemia. Peri-operative acute kidney injury is associated with an increased risk of short- and long-term postoperative complications, including a longer stay in hospital, development of premature chronic kidney disease and increased mortality. Resource utilisation and healthcare costs are also higher. In future, the development of advanced clinical prediction scores, new imaging and monitoring techniques and the application of new biomarkers for acute kidney injury have the prospect of identifying acute kidney injury earlier and allowing a more personalised management approach with the aim of reducing the global burden of acute kidney injury.

[Complication of acute diverticulitis: colo-vesical fistula (a clinical case)]. / Una complicanza della diverticolite acuta: la fistola colo-vescicale (Caso Clinico).

BACKGROUND: A patient presenting a colo-vescical fistula together with a number of other pathologies, and the absolute absence of a set scheme for the treatment of septic diverticular complications has prompted us to publish this case. PATIENT AND METHODS: The patient aged 80 was admitted urgently, diagnosed with intestinal occlusion. Generally poor conditions: renal insufficiency, abdomen globose and hypertympanic, systaltic mass in the epigastric site. The patient had experienced abdominal pains for about 4 months; severe tenesmo during evacuation: fever temperature as high as 38.5 degrees C; dysuria; aero-hydro levels; stenosis of the sigmoid. A decision was taken to operate. SURGERY: The presence of a large mass at the level of the sigmoid, which subsumed the ileal ansae, the vescical and the sigmoid itself. While isolating the pelvic anatomical structures, a purulent sac in the Douglas was uncovered, which united the bladder and the sigmoid. It was thought appropriate only to fit a colostomy, thus excluding the descendents. DISCUSSION: Surgery must resolve the peritonitis and the fenestration itself. Due to the existing septic conditions, it was not believed advisable to perform a primary anastomosis; a Hartmann's or a simple colostomy was thought preferable. CONCLUSIONS: This case underlines the difficulty in standardising operational conduct when this in turn will depend on the experience of the operator and the circumstances met at the time.

The first-reported case of diffuse purulent peritonitis in a patient with retroperitoneal Hodgkin disease (etiopathogenetic hypotheses).

We report a case of purulent diffuse peritonitis in a patient who was affected by Hodgkin lymphoma, with no evidence of other abdominal diseases. This is a 54 y. old. white male who was admitted to our department with a history of asthenia, recurrent fever, dysphagia and abdominal pain. In the plain abdominal radiology pneumoperitoneum was evident. Duodenal perforation suspicion was confirmed by anamnesis and plain radiology which showed the presence of intra abdominal air. Emergency exploratory laparotomy showed a purulent diffuse peritonitis, which relapsed after multiple surgical toilettes and peritoneal lavage. A postoperative abdominal CT scan and histology of a biopsy taken during the second surgical operation showed a retroperitoneal Hodgkin lymphoma, which went to remission after chemotherapy. Considering the two simultaneous clinical manifestations (retroperitoneal Hodgkin lymphoma and peritonitis), we made two pathogenetic hypotheses: a) The retroperitoneal disease produced lymphatic stagnation and peritoneal transudation, which then was infected; b) The abnormal lymph nodes were infected and the abdominal cavity was contaminated from retroperitoneum from blood/lymphatic stream or by contiguity.

A rare gastric ulcer complication: the gastrocolic fistula. A case report.

We report a case of gastrocolic fistula following a benign gastric ulcer, which is now a truly exceptional finding, due to the widespread use of H2-receptor antagonists and proton- pump inhibitors. A review of the literature shows that this condition warrants a complete diagnostic work-up to exclude more ominous underlying diseases. Careful attention to the symptoms of peptic ulcer and particular care with patients undergoing long-term treatments with drugs potentially harmful for the stomach are recommended.

[Meckel's diverticulum. Our experience]. / Il diverticolo di Meckel. Nostra esperienza.

BACKGROUND: The paper aimed to highlight the percentage presence of Meckel's diverticulum compared to appendiceal pathology in a retrospective study and whether its surgical removal is always useful, even if asymptomatic. METHODS: The study was performed at the Institute of Emergency Surgery at the Second University of Naples (Head: Prof. R. Docimo) in 1211 patients affected by appendiceal-like pathology, reported to the authors' attention for both elective and emergency surgery from 1973 to today. The presence of Meckel's diverticulum was rarely diagnosed in preoperative patients; it was occasionally found in both elective surgery in patients with other abdominal pathologies, above all appendicitis, and in patients undergoing emergency surgery for acute pathologies (occlusion, peritonitis) caused by the former. The diverticulum was always totally removed (diverticulectomy or intestinal resection) even when it was asymptomatic. RESULTS: The results were satisfactory in all patients and at the one-year follow-up none complained of discomfort. CONCLUSIONS: We are convinced that Meckel's diverticulum should be investigated as a matter of course during appendectomy and, where present, it should be removed even if asymptomatic because the problems arising secondary to complications are undoubtedly more severe compared to any discomfort following its surgical removal.

[Evolution of the surgical treatment of rectal cancer. Our experience]. / L'evoluzione nel trattamento chirurgico del cancro del retto. Nostra esperienza.

In this study we have reviewed our data from 1973 to 1998 and we have compared three intervals. In each of these periods we have performed the same type of surgery which enables the comparison of adopted techniques with obtained results. During the first period (1973-1980) we have treated 65 cases of rectum cancer staging between B2 and D, which were mainly localised in the medium rectum (41.2%). During the second period (1981-1990) we have treated 44 cases with a majority of patients staging B2. The localisation was again mainly in the medium rectum (38.5%). During the third period (1981-1998) we have treated 37 cases of rectum cancer staging between A2 and B1. Again the most frequent site was the medium rectum (48.9%). Consequently, we compared the staging, the type of surgery and the complications for the three periods. Our results show that the survival time was 5 years, in 70% of the cases where an anterior resection was performed, but this percentage decreased substantially if we also considered patients presenting with an advanced staging (C2-D), in which the only type of surgery that could be performed was colostomy or the simple explorative laparotomy.

Warthin's tumour in the parotid gland (an inflammatory or a neoplastic disease?).

Warthin's tumour has always been considered a peculiar neoplasm with specific anatomico-pathological characteristics. In this study we argue that it should not be considered a true neoplasm but simply an inflammatory process which is triggered by the indiscriminate use of tobacco and involves the parotid duct. In the 10 cases treated in our department, Warthin's tumour has predominantly affected males (9:1) and heavy smokers. Our treatment of choice has been enucleoresection. The results have been satisfactory, with no complications such as salivary fistula or permanent lesions of the facial nerve. In two subjects, treated by enucleoresection, there was a pleomorphic adenoma: in one on the same side as previous surgery performed two years earlier and, in the second, in the contralateral gland 4 years after surgery. Both patients, who underwent total parotidectomy, recovered perfectly without complications. Smoking appears to be involved in the development of Warthin's tumour and might be regarded as an inflammatory reaction to smoking or to ionising radiation. Ultrasound and FNAB are necessary for planning the correct surgical strategy, and enucleoresection, in our opinion, is the treatment of choice.