Biliodigestive fistulae and gallstone ileus: diagnostic and therapeutic considerations. Our experience.

The biliodigestive fistula is not a rare affection in the context of acute pathology of the gastrointestinal tract. It often affects patients between 63 and 85 years old , particularly the female sex, and the most common cause is acute or chronic cholecystolithiasis. Open issues are the delayed in the pre-operative diagnosis, and controversies exist regarding the best surgical approach. The choice of treatment options is influenced by the age of the patients and their clinical conditions and also by the presence of comorbidities and of a delayed right diagnosis. In the 1 to 3% of cases, the biliodigestive fistula presents a gallstone ileus as complication, whose diagnosis is particularly difficult for the lack of specific signs and symptoms. The contrast-enhanced CT is considered the gold standard for a specific pre-operative diagnosis, as it directly shows the fistula. Surgical treatments include one-stage procedure or two-stage procedure. Many studies seem to favor a deferred definitive procedure. The Authors describe 4 cases: in 3 cases, women between 70 and 80 years old presenting an history of recurrent cholecystitis, in 2 cases, and in 1 case presenting a bowel obstruction; in 1 case a 50-years-old man, with no significant past medical history, presenting a bowel obstruction. The Authors have performed in the 2 cases of gallstone ileus an enterolithotomy with cholecysto-duodenal fistula repair and cholecystectomy, in one-stage, and this has been possible because of the good clinical conditions of the patients and their low operative risk. In the case of fistula without the complication of gallstone ileus, the treatment approach has been cholecysto-gastric fistula closure with a gastroplastic using separate stitches and cholecystectomy, in one-stage. We are in agreement with data in the literature regarding the delay into the diagnosis of biliodigestive fistula and with the importance to suspect it or gallstone ileus presence, although the clinical presentation is extremely non-specific. In our experience, cholangiopancreatography-CT and CECT have made easier the pre-operative diagnosis and so reducing the delay of the treatment.

Small bowel intussussception due to metastatic melanoma of unknown primary site. Case report.

Malignant melanoma is characterized by metastases also to the gastrointestinal tract, especially in the small bowel. The diagnosis is often delayed because unspecific clinical presentation (frequently as chronic iron deficiency anemia, rectal bleeding or intestinal obstruction). We present a case of melanoma of unknown primary site, with clinical presentation of intestinal obstruction. A segmental resection of the ileum was performed including mesentery with lymph nodes. Histology revealed metastatic melanoma from unknown primary. PET and MRI confirmed disseminated disease without brain metastasis.

Risk management in surgery.

Malpractice is the responsible for the greatest number of legal claims. At the present time, legal actions against physicians in Italy are 15,000 per year, and a stunning increase about costs to refund patients injured by therapeutic and diagnostic errors is expected. The method for the medical prevention is "Risk Management", that is the setting-up of organizational instruments, methods and actions that enable the measurement or estimation of medical risk; it allows to develop strategies to govern and reduce medical error. In the present work, the reconstruction about the history of risk management in Italy was carried out. After then the latest initiatives undertaken by Italy about the issue of risk management were examined.

Single-incision laparoscopic appendectomy is comparable to conventional laparoscopic and laparotomic appendectomy: our single center single surgeon experience.

Several studies have demonstrated the clinical and technical benefits of the laparoscopic surgery for complicated and uncomplicated appendicitis. Our retrospective study included 12 patient who underwent SILS appendectomy (SILS-A), 14 who received conventional laparoscopic surgery (VL-A), and 12 who received laparotomic appendectomy (OA); performed in all cases by the same surgeon (C.F.). The aim of this study was the comparison between this three different surgical techniques on same features: post operative leukocytosis, post operative pain, need abdominal drainage, esthetic viewpoint, incidence of complication, hospital stay. The results showed no significant differences between SILS-A and VLS-A, while an evident improvement shows versus O-A, even though not statistically significative. SILS was more effective in decreasing the risk of postoperative wound infection.

Technique and outcomes about a new laparoscopic procedure: the Pelvic Organ Prolapse Suspension (POPS).

Pelvic organ prolapse suspension (POPS) is a recent surgical procedure for one-stage treatment of multiorgan female pelvic prolapse. This study evaluates the preliminary results of laparoscopic POPS in 54 women with a mean age of 55.2 and a BMI of 28.3. Patients underwent at the same time stapled transanal rectal resection (STARR) to correct the residual rectal prolapse. We had no relapses and the preliminary results were excellent. We evaluated the patients after 1 year follow-up and we confirmed the validity of our treatment. The technique is simpler than traditional treatments with an important reduction or completely disappearance of the pre-operative symptomatology.

Cholecystectomy by single incision laparoscopic surgery (SILS): early experience and technique standardization.

Single Incision Laparoscopic Surgery (SILS) is a recent surgical technique, first described in the 1990s. Its aim is to optimize the esthetic result offered by laparoscopy by minimizing the number of abdominal incisions. Various preliminary studies have been carried out on the application of SILS, especially in cholecystectomy and appendectomy. This study evaluates the preliminary results of cholecystectomy by SILS (SILS™ Port) conducted between October 2009 and February 2011 on 21 patients (4 men and 17 women) with a mean age of 49.9 years and a mean Body Mass Index (BMI) of 22.8. All patients were treated by the same team, which had previously undergone six months' simulator training. There were two main selection criteria, both evaluated intraoperatively: absence of adhesions and of significant inflammatory sequelae from previous cholecystitis; and suitable distance between gallbladder and SILS access port. Conversion to traditional laparoscopy was necessary in just two cases, while an accessory trocar was introduced in another two cases. Conversion to open surgery was not necessary in any case. One case of SILS cholecystectomy was complicated by postoperative bile leakage, which was treated conservatively, as the fistula had a low output. The mean duration of hospitalization was 3.6 days. This preliminary experience led us to conclude that SILS is safe and highly satisfactory in the postoperative phase, thanks to the reduced need for painkillers and the improved esthetic result.

Liver resection for hemoperitoneum caused by spontaneous rupture of unrecognized hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is an increasingly common form of cancer. Although its spontaneous rupture is rare in Western countries, it constitutes a surgical emergency and is associated with high mortality. There is a lack of consensus as to the best approach and what parameters to use in choosing it. The three main approaches are conservative, endovascular and resection - the treatment of choice for acute abdominal bleeding. We report a case of hemoperitoneum following the spontaneous rupture of an unrecognized HCV-related HCC in a patient with no history of liver disease. The patient was successfully treated by emergency surgery, with resection of two segments of the left liver.

Alteración de la calidad de vida en 785 pacientes con rinitis alergica / Imaired quality of life in 785 patients with allergic rhinitis

La incorporación del concepto "Calidad de Vida" ha generado entre los médicos y el personal relacionado con la salud, un cambio de actitud en el cual el único objetivo es el beneficio del paciente. "La calidad de vida relacionada con la salud evalúa no sólo las alteraciones producias por la enfermedad, sino el modo en que el paciente las percibe y los efectos beneficioso o no del tratamiento. Objetivo: describir la frecuencia de las alteraciones de la calidad de vida en pacientes con rinitis.

The object to study was to evaluate quality of life in patients with rhinitis.

[Massive lower gastrointestinal bleeding due to diverticular disease during antiplatelet therapy. Case report]. / Enterorragia massiva da diverticolosi sigmoidea in corso di terapia antiaggregante. Caso clinico.

Diverticular disease is very frequent in Western countries; in 5% of the cases it is the cause of serious bleeding, haemodynamic instability and death. The authors report a case of 74 years old patient with severe lower gastrointestinal bleeding. She was in antiplatelet treatment with acetylsalicylic acid (100 mg/die) and clopidogrel (75 mg/die) for preventing the restenosis of medicated stents positioned to treat an acute coronary syndrome. At the same time the patient was under treatment for primary hypercholesterolemia with rosuvastatin (20 mg/die). The severe haemorrhage demanded haemodynamic stabilization, achieved by colloid infusion and blood transfusions. The bleeding continued; selective arteriography showed it's origin from the areas of the sigmoid and superior hemorrhoidal arteries. During the procedure, embolization of the inferior mesenteric artery using spiral type BALT was performed, with consequent bleeding interruption. Fifteen days after the embolization, a rectosigmoid colonoscopy showed a sigmoid diverticular disease. The treatment with acetylsalicylic acid and clopidogrel has surely contributed to the severity of the hemorrhage. Recent experimental and clinical evidence suggests a possible antiplatelet effect of the statins.

[Traumatic retroperitoneal haematoma]. / L'ematoma retroperitoneale post-traumatico.

The management of traumatic retroperitoneal haematomas is still a much debated question. Although the diagnosis has become easier using CT with contrast medium, the therapeutic decisions are still difficult because of the great variability of the lesions, which may be simple but very often complicated. Our study is based on 1086 treated patients, 29.5% of the 3682 critical abdominal polytrauma seen in 35 years. Mortality has been 12.9% with a medium ISS (Injury Severity Score) of 23.4. 71.4% of the cases were closed traumas, 28,6% were open traumas. The most common single lesions have been pelvic (43%), followed by the renal traumas (39%). Regarding the associated lesions, the thoracic traumas cause an increment of the ISS score up to 26.2% and of mortality up to 14.6%. The maxillofacial traumas associated with traumatic retroperitoneal haematomas represent 11%, mainly associated with motorcycle accidents, which have increased in the last years from 2,4% in the 70s to 32% these days. Our approach to these patients has been basically conservative. Following the indications obtained by the CT, we widely used interventional angiography, especially for renal lesions and, after pelvic stabilization, for pelvic haematomas. We have chosen surgery considering the kind of traumas (open or closed), the location of the haematoma and especially, the clinical course of the patient's hemodynamic condition.

[Gastrointestinal opportunistic infections and human immunodeficiency virus (HIV). Case report]. / Infezioni opprtuniste gastrointestinali e HIV. Caso clinico.

There have been millions of people found to have AIDS. Death rates from AIDS have declined 15% to 20% in the past 5 years. However, nearly 75000 people will die with AIDS in this year. Patients with AIDS are also at risk for developing both Aids-defining cancers, such as Kaposi's sarcoma and non-Hodgkin lymphoma, and non-Aids-defining cancers and opportunistic infections. In patients with advanced Aids, the Cytomegalovirus is a frequent cause of chorioretinitis, pneumonitis, chronic perineal ulcerations and oesophagitis. It has been involved in endocrine, bone marrow, central nervous system and kidney abnormalities. CMV infection of the small bowel accounts for only 4.3% of all cytomegalovirus infection of the GI tract (large bowel 47%, duodenum 21,7%, stomach 17,4%); isolated cases of small bowel perforation due to CMV have been reported in AIDS patients, and all but one patient died. The Authors report a rare case of an HIV-positive young man with gastroenteric Cytomegalovirus infection responsible for generalized peritonitis from multiple perforations.

Descriptive data on lifestyle, anthropometric status and mental health in italian elderly people.

OBJECTIVE: The objective of this paper is to provide descriptive information on anthropometric status, pathological conditions, cognitive impairment and lifestyle in apparently healthy elderly Italian people. DESIGN, SETTING AND SUBJECTS: In order to recruit the volunteers for the ZENITH study, 359 Italian participants (167 men and 192 women), aged between 70 and 85 years, free living in Rome, were selected. Volunteers underwent a full clinical examination, anthropometric measurements (height, weight), a lifestyle questionnaire and mental health assessment (cognitive impairment and depression). RESULTS: The prevalence of overweight and obesity was high (57% and 22% in men; 43% and 27% in women). Obesity was associated with low socio-economic profile in about 40% of participants. Although the sample was selected by family doctors and was apparently healthy, after medical screening the presence of several pathologies, particularly diabetes in 21% of participants was observed. There was a low prevalence of cognitive impairment in 4% of men and 7% of women and possible depression in 9% of men and 19% of women. The lifestyle questionnaire showed that most of their time was spent in light activities such as reading, watching TV or playing cards and significant differences between sex and BMI categories were observed (P=0.000). CONCLUSION: The results confirm the increasingly sedentary lifestyle of modern populations and demonstrate the need for sensitive and individualised strategies to design appropriate health promotion and disease prevention programs for older adults.

Sigmoid colon injury due to blunt abdominal trauma. A case report.

We present a case of sigmoid colon injury after blunt abdominal trauma. The patient was submitted to sigmoid resection with primary end-to-end colo-colic anastomosis. He died 22 days after operation with septic shock and acute respiratory failure. Post-mortem examination showed left lung generalized pneumonia with no signs of intra-abdominal pathology; colo-colic anastomosis was intact. We reviewed the literature about the management of this rare trauma.

[The femoral hernia: problems in emergency surgery]. / L'ernia crurale: problematiche chirurgiche in urgenza.

The femoral hernia can be defined as infrequent, and predominantly found in females, with the highest incidence between 30 and 40 years of age. It shows a high tendency to strangulation, also up to 40% of cases, due to the presence of the Gimbernat ligament, which with its tense fibrous margins, aids strangling known as "raised crest". The diagnosis may not be easy, overall in the clinical presence of acute abdomen in elderly patients, disabled people or people who are uncooperative during physical examination. Therefore, it should be sought with an adequate bilateral exploration of the region in all occlused patients and especially with the use of radiological images of the small intestine. The solution currently practiced is prosthetic, proposed by Lichtenstein, and variously modified by Gilbert, Rutkow, Bendavid, and other which uses a prolene plug in the shape of a cigar, umbrella, or basket, according to the size and characteristics of the parietal defect. In emergency conditions, the technique doesn?t change; but if there is stercorary contamination, it is advisable to use direct repair according to the old method of Bassini. In the last 10 years, we have treated 37 femoral hernias in emergency, using direct repair in only 2 cases. In 3 cases we used PTFE; in the other 32 cases prolene was always used; 20 patients were operated under local anesthetic, 12 under general anesthetic and 5 under peridural anesthetic. Satisfactory results were achieved, with average hospital recovery time of 1.4 days, with an early recovery between 3 and 5 days, with only 2 relapses.

[Prevention of post-operative pain and haemorrhage in PPH (Procedure for Prolapse and Hemorrhoids) and STARR (Stapled Trans-Anal Rectal Resection). Preliminary results in 261 cases]. / La prevenzione del dolore e dell'emorragia post-operatoria nella PPH (Procedure for Prolapse and Hemorrhoids) e nella STARR (Stapled Trans-Anal Rectal Resection). Risultati su una serie di 261 pazienti.

Intra- and early (first week) post-operative haemorrhages are the most common complications in stapled hemorrhoidectomy PPH (Procedure for Prolapse and Hemorrhoids) and in circumferential resection of the rectal prolapse STARR (Stapled Trans Anal Rectal Resection). Performing PPH and STARR we employed a gelatin based haemostatic sealant with thrombin component (FloSeal) to control intra-operative bleeding and to reduce post-operative bleeding avoiding haemostatic stitches on suture line. We report the preliminary results on 197 PPH and 64 STARR; 44 PPH (22.4%) and 27 STARR (42.2%) were treated by FloSeal. No major post-operative bleeding was observed in all patients treated by FloSeal, compared to 1.3% and 2.7% of hemorrhage respectively in PPH and STARR patients treated without sealant. Post-operative pain was less severe in patients treated by FloSeal, without a difference statistically significant. The data are preliminary and must be confirmed in prospective randomized trials in larger series.

Gastrointestinal surgical emergencies in patients treated for hemathological malignancies.

BACKGROUND: Upper and lower gastrointestinal symptoms are major and serious complications in patients who undergo chemotherapy for hematological malignancies. Their most frequent causes are acute intestinal graft-versus-host disease (GVHD) after bone marrow transplant, infections, toxicity or preexisting gastrointestinal diseases. Mortality can reach 30-60% of cases. PATIENTS AND METHODS: We report 15 cases operated on for abdominal emergencies: 3 severe gastrointestinal bleeding and 12 acute abdomen. RESULTS: We performed 10 bowel resections, one cholecystectomy, one splenectomy, two laparotomy with pancreatic debridement and peritoneal lavage, and one suture of perforated peptic ulcer. Operative mortality was 33.3% (5/15). Deaths have been reported only in the group of patients with acute abdomen. In all cases death was correlated to generalized sepsis related to immunosuppression. CONCLUSIONS: We believe that an aggressive approach, consisting of close monitoring and early laparotomy combined with vigorous supportive therapy, should be used when dealing with suspected gastrointestinal complications in patients with hematological malignancies.

[Glomus tumor and neovascular syndrome of the arm: a clinical case]. / Tumore glomico e sindrome neurovascolare dell'arto superiore: caso clinico.

Glomus tumour represents a benign tumor which originates from myoepithelial cells of arteriovenous anastomosis that has a preference for subungual localization with painful and multiform symptomatology. A fifty-year-old female presented a vasospastic symptom with hyperalgesia and cold hypersensitivity in the fourth finger of the right hand. There was a little palpable tumefaction and after an echography, we decided for surgical revision. Differential diagnosis with Raynaud's phenomenon is very important but not simple. The diagnosis is often late. MRI and angio-MR with its typical symptomatology could give the accurate diagnosis. The therapy is only surgical. The excision must be very careful making sure to spare the nervous structures.