Socio-economic inequalities in the use of drugs for the treatment of chronic diseases in Italy.

BACKGROUND: Since the use of medicines is strongly correlated to population health needs, higher drug consumption is expected in socio-economical deprived areas. However, no systematic study investigated the relationship between medications use in the treatment of chronic diseases and the socioeconomic position of patients. The purpose of the study is to provide a description, both at national level and with geographical detail, of the use of medicines, in terms of consumption, adherence and persistence, for the treatment of major chronic diseases in groups of population with different level of socioeconomic position.  METHODS: A cross-sectional study design was used to define the "prevalent" users during 2018. A longitudinal cohort study design was performed for each chronic disease in new drug users, in 2018 and the following year. A retrospective population-based study, considering all adult Italian residents (i.e. around 50.7 million people aged ≥ 18 years). Different medications were used as a proxy for underlying chronic diseases: hypertension, dyslipidemia, osteoporosis, diabetes and chronic obstructive pulmonary disease. Only "chronic" patients who had at least 2 prescriptions within the same subgroup of drugs or specific medications during the year were selected for the analysis. A multidimensional measures of socio-economic position, declined in a national deprivation index at the municipality level, was used to identify and estimate the relationship with drug use indicators. The medicine consumption rate for each pharmacological category was estimated for prevalent users while adherence and persistence to pharmacologic therapy at 12 months were evaluated for new users. RESULTS: The results highlighted how the socioeconomic deprivation is strongly correlated with the use of medicines: after adjustment by deprivation index, the drug consumption rates decreased, mainly in the most disadvantaged areas, where consumption levels are on average higher than in other areas. On the other hand, the adherence and persistence indicators did not show the same trend. CONCLUSIONS: This study showed that drug consumption is influenced by the level of deprivation consistently with the distribution of diseases. For this reason, the main levers on which it is necessary to act to reduce disparities in health status are mainly related to prevention. Moreover, it is worth pointing out that the use of a municipal deprivation indicator necessarily generates an ecological bias, however, the experience of the present study, which for the first-time deals with the complex and delicate issue of equity in Italian pharmaceutical assistance, sets the stage for new insights that could overcome the limits.

INCIDENTAL PARATHYROIDECTOMY DURING TOTAL THYROIDECTOMY AS A POSSIBLE RISK FACTOR OF HYPOCALCEMIA. EXPERIENCE OF A SINGLE CENTER AND REVIEW OF LITERATURE.

CONTEXT: Post-operative clinical and biochemical hypocalcemia is a common complication of thyroid surgery and the correlation with incidental parathyroidectomy (IP) remains controversial. OBJECTIVE: To evaluate the incidence of IP during TT, its correlation to early post-surgery hypocalcemia, and its potential risk factors. PATIENTS AND METHODS: 77 consecutive patients submitted to thyroid surgery between January 2018 and December 2019. Demographic, clinical, biochemical, surgical and histopathological factors were assessed. Statistical multivariate analysis was performed to identify the risk of IP. RESULTS: IP was evident in 22 (28.5%) patients who underwent TT, TT with lymph node dissection of the central compartment (CLND) and reoperation for previous hemithyroidectomy with CLND. Early symptomatic hypocalcemia 24 hours after TT was demonstrated in 12/22 (54.5%) patients, with PTH value of <14pg/mL in 7/12 (58.3%) patients, and in 6 of these 7 patients (85.7%) the PTH value was <6.3pg/mL. In 5/22 (22.7%) patients the IP was associated with biochemical hypocalcemia <8.4mg/dL, and in 5/22 (22.7%) patients anatomical damage was not associated with a reduction in plasma calcium levels. The severity of early post-op hypocalcemia was not correlated with the number of parathyroid glands left in situ. The multivariate analysis did not show statistically significant values between the clinical-pathological variables and increased risk of IP. CONCLUSIONS: No IP clinical-pathological risk factors have been identified during thyroid surgery. In all cases of TT, with or without CLND, the meticulous identification of the parathyroid glands, whose incidental removal is frequently associated with clinical and biochemical hypocalcemia, is recommended.

Forest carbon sink neutralized by pervasive growth-lifespan trade-offs.

Land vegetation is currently taking up large amounts of atmospheric CO2, possibly due to tree growth stimulation. Extant models predict that this growth stimulation will continue to cause a net carbon uptake this century. However, there are indications that increased growth rates may shorten trees' lifespan and thus recent increases in forest carbon stocks may be transient due to lagged increases in mortality. Here we show that growth-lifespan trade-offs are indeed near universal, occurring across almost all species and climates. This trade-off is directly linked to faster growth reducing tree lifespan, and not due to covariance with climate or environment. Thus, current tree growth stimulation will, inevitably, result in a lagged increase in canopy tree mortality, as is indeed widely observed, and eventually neutralise carbon gains due to growth stimulation. Results from a strongly data-based forest simulator confirm these expectations. Extant Earth system model projections of global forest carbon sink persistence are likely too optimistic, increasing the need to curb greenhouse gas emissions.

Total thyroidectomy associated to chemotherapy in primary squamous cell carcinoma of the thyroid.

Primary squamous cell carcinoma of the thyroid (PSCCT) is a rare malignant disease with rapid fatal prognosis. The onset is generally characterized by sudden bilateral latero-cervical lymphadenopathy. The Authors report patient of 58-year-old who referred for evaluation of rapidly aggravating bilateral latero-cervical lymphadenopathy. The US highlighted the presence of a hypoechoic nodular lesion characterized by peri and intra-nodular vascularization. Multilayer CT showed diffused involvement of mediastinal and bilateral latero-cervical lymph nodes, with no evidence of primary pulmonary neoplasia or elsewhere. The patient underwent total thyroidectomy. The peri-isthmic tissue was removed due to the presence of a small roundish formation, that was due to lymph node metastasis at histological examination. Histological diagnosis: PSCCT. The immunohistochemical panel of the thyroid lesion was indispensable for the differential diagnosis between PSCCT, medullary carcinoma, anaplastic carcinoma, and thyroid metastasis of neoplasia with unknown primitiveness. The patient underwent chemotherapeutic treatment with Carboplatin and Paclitaxel with modest improvement of dysphagia symptoms and reduction of 10-15% of the target lesions. The clinical course was characterized by loco-regional progression of the disease with exitus in 10 months after diagnosis. Survival and quality of life after surgical therapy and chemotherapy were like that of patients undergoing only chemotherapy. Due to the extreme rarity of the neoplasia, 60 cases described in Literature, no exclusive guidelines are reported for PSCCT. More extensive case studies are needed to evaluate the effects of total thyroidectomy with intent R0/R1 on improving survival and quality of life of patients with PSCCT.

Bilateral hydrocele. Uncommon clinical presentation of primary testicular lymphoma in the elderly.

Primary testicular lymphoma (PLT) represents 5% of testis tumors, the incidence increases in patients older than 60 years of age. Bilateral hydrocele is an unusual clinical presentation. Relapse in the central nervous system and in the contralateral testis is often observed. The US shows hypoechoic nodular lesions with a complete structural involvement of didymus and hypervascularization at Color Doppler. Orchiectomy should be performed in all cases as it is indispensable for the histopathological diagnosis and to characterize the immunophenotypic features. The most common histotype is diffuse large-B cell lymphoma. Combined biological approach and chemotherapy with rituximab and doxorubicin has radically changed the prognosis of disease. The authors report two patients of 81 and 82 years-old who referred for evaluation of massive bilateral hydrocele causing severe limitation of deambulation. Negative cytological findings for neoplastic cells in the scrotal effusion made difficult the differential diagnosis between inflammatory and malignant disease. Histopathologic findings made a diagnosis of high grade diffuse large B-cell NHL, respectively stage IV-E and stage III-E. The 82 years old patient was treated with 6 chemotherapy cycles of rituximab, cyclophosphamide, vincristine, prednisone. The exitus was dued to the umbilical hernia complications. In the 81 years old patient, cognitive deficit and severe impairment of general conditions constituted an absolute contraindication to polychemotherapy treatment. Rapid tumor progression led the patient to exitus 2 months after diagnosis. In both patients the delayed diagnosis of PLT was probably due to the reduction of welfare protection in the elderly with adverse social conditions.

The influence of residents in the outcome of elective laparoscopic surgery: a prospective study comparing a teaching hospital and a private community hospital in Italy.

OBJECTIVES: We compared the outcome of elective laparoscopic cholecystectomy (LC) in a teaching hospital and a private communityhospital to assess the impact of the involvement of residents. MATERIALS AND METHODS: The following parameters were studied prospectively in patients who underwent elective LC during the period from September 2014 to February 2016 in a teaching university hospital (group A) and in a private community hospital (group B): age, sex, body mass index (BMI), comorbidities, American Society of Anaesthesiologists (ASA) score, length of surgery from skin incision to skin closure, use of drain, 30-day perioperative morbidity and mortality, and length of postoperative hospital stay. RESULTS: The group A consisted of 93 elective LC and the group B of 167 elective LC. Operative time was significantly longer in group A. Intraoperative complications were similar and no conversion was necessary in both groups. An increased rate of postoperative complications was observed in group A. All postoperative complications were managed with conservative therapy. No mortality occurred. At logistic regression analysis, the only factor favouring the occurrence of complications was the hospital type. CONCLUSIONS: Our study shows that elective LC can be performed in a teaching hospital with comparable intraoperative morbidity and increased postoperative complications. The greater rate of morbidity found in the teaching hospital may be due to an increased vigilance linked to the presence of residents and not to the lack of expertise.

Challenging differential diagnosis between lipoma and well-differentiated liposarcoma in the retroperitoneum. A case report.

Liposarcomas are the most common type of sarcomas arising in the retroperitoneum. Retroperitoneal lipomas are extremely rare. They should be distinguished from well-differentiated liposarcomas in order to provide the appropriate treatment. A 53-years-old male was admitted with the presence of a palpable mass in the upper abdomen. Contrast enhanced computerized tomography (CT) of the abdomen and pelvis showed a 20x12 cm mass arising in the retroperitoneum and inglobing the celiac and superior mesenteric trunks. Because of unresectability an open surgical biopsy was performed. Histological examination showed the presence of adipose tissue with diffuse liponecrosis without definitive features of neoplasia. At six-month follow-up a CT documented an increase of the tumor to 22x13 cm. The mass was stable at the CT, performed at 1-year follow-up. Given the impossibility to distinguish well-differentiated liposarcomas from lipomas and the in the present case of unresectable retroperitoneal mass, an observational follow-up was a justified.

Transanal haemorrhoidal dearterialisation with mucopexy versus stapler haemorrhoidopexy: a randomised trial with long-term follow-up.

INTRODUCTION: The present study aimed to compare the long-term results of transanal haemorrhoidal dearterialisation (THD) with mucopexy and stapler haemorrhoidopexy (SH) in treatment of grade III and IV haemorrhoids. METHODS: One hundred and twenty-four patients with grade III and IV haemorrhoids were randomised to receive THD with mucopexy (n=63) or SH (n=61). A telephone interview with a structured questionnaire was performed at a median follow-up of 42 months. The primary outcome was the occurrence of recurrent prolapse. Patients, investigators and those assessing the outcomes were blinded to group assignment. RESULTS: Recurrence was present in 21 patients (16.9%). It occurred in 16 (25.4%) in the THD group and 5 (8.2%) in the SH group (p=0.021). A second surgical procedure was performed in eight patients (6.4%). Reoperation was open haemorrhoidectomy in seven cases and SH in one case. Five patients out of six in the THD group and both patients in the SH group requiring repeat surgery presented with grade IV haemorrhoids. No significant difference was found between the two groups with respect to symptom control. Patient satisfaction for the procedure was 73.0% after THD and 85.2% after SH (p=0.705). Postoperative pain, return to normal activities and complications were similar. CONCLUSIONS: The recurrence rate after THD with mucopexy is significantly higher than after SH at long-term follow-up although results are similar with respect to symptom control and patient satisfaction. A definite risk of repeat surgery is present when both procedures are performed, especially for grade IV haemorrhoids.

[The age factor in bilateral hydrocele diagnosis secondary to a primitive testis lymphoma: case report, diagnosis and therapy]. / Il fattore età nella diagnosi clinica di idrocele bilaterale da linfoma primitivo del testicolo: caso clinico e considerazioni diagnostico-terapeutiche.

Primitive NHL represents 9% of testis tumours and the 85% is diagnosed in patient older thant 60 years old. Usually pain and a testis mass are the main manifestations. The Authors report the case of a 82 years-old man with bilateral hydrocele causing severe alteration in the deambulation. The cytology did not show blood cells or neoplastic cell in the FNAB. The US showed a complete modification in the testis. The patient underwent to surgery intervention of vaginalis tunic eversion and resection with the aim of control the symptoms. The histology on multiple biopsy of testis and epidydims bilaterally showed a large B-cell lymphoma. The patient was treated with 6 chemotheray cycles (Rituximab, Vincristine, Cyclophosphamide, Prednisone). Bilateral hydrocele is a rare clinical presentation of testis NHL. In this patient, blood and neoplastic cell absence in the cytology made difficult the differential diagnosis between inflammatory pathology and neoplasia. Hystopathologic study and immunologic pattern can make a certain diagnosis.

Ultrasound identification of nerve cords in the infraclavicular fossa: a clinical study.

BACKGROUND: This study aimed to analyze nerve trunk anatomy in the infraclavicular fossa and to correlate these data with the most common anthropometric parameters. METHODS: A Mylab 30 Gold (Esaote) and the linear transducer LA523 (7.5 MHz frequency) were used. The probe was oriented according to a parasagittal plane, parallel to the lateral chest wall and immediately medial to the coracoid process underneath the clavicle. Measurements included the distance between the artery and the cutaneous surface (mm) and the apical corner of the ultrasound image (mm), the number of identified nervous cords and their position related to the axillary artery, and the position and number of axillary veins. Sex, age, height, weight, body mass index (BMI), biceps girth, and breast size were recorded. Statistical analysis included calculation of linear Pearson correlation coefficient and Student's t test. RESULTS: Two hundred and two consecutive patients were enrolled. The position of the three cords was highly variable around the artery. In a small but significant percentage of patients (8.9%), the medial and the lateral cords were located together at the top of the artery. The visibility of the trunks and the distance between the upper part of the artery and the apical corner of the ultrasound image correlated with anthropometric characteristics. The vein position with respect to the artery and nerves was markedly variable. CONCLUSION: Sono-anatomic study of the infraclavicular region adds important data that is useful when conducting nerve blocks to improve safety and likelihood of success.

[Factors associated with ileal-pouch related fistulas in 100 consecutives patients who underwent restorative proctocolectomy]. / Fattori associati alla comparsa delle fistole pouch-correlate in uno studio su 100 pazienti sottoposti a pouch ileo-anale.

OBJECTIVE: The pouch-related fistulas range in literature from 2% to 16% and they can be cause of failure of the intervention of restorative proctocolectomy. Aim of this study was to examine factors associated with theirs development and to identify theirs possible etiology and pathogenesis. MATERIALS AND METHODS: Retrospective study focusing on 100 consecutive patients who underwent restorative proctocolectomy with pouch-anal anastomosis (IPAA). Patients with fistula and patients without fistula have been identified and the fistula type, the time from surgery and the site relative to IPAA have been recorded. Patients' demographics, co-morbidity or related medical history, clinical indication for treatment, surgical method, histological diagnosis, length of follow-up, early and late postoperative complications have been reviewed, and data collected have been compared among the two groups through univariate analysis. RESULTS: The overall incidence of fistulas was of 10% (10 cases); 8 cases had pouch-vaginal fistulas, involving the distal tract of the vagina, and associated with pouch-perineal fistulas in 2 cases; 1 case had pouch-vulval fistula; 1 case had a complex pouch-perineal fistula. Three fistulas were precocious, all associated with an IPAA leak; 2 of these cases also had pelvic sepsis while the third had delayed diagnosis of Crohn’s disease. Seven fistulas had a late development. Four fistulas occurred at the level of the IPAA; 5 fistulas were located below the IPAA, and 1 fistula originated above and below the IPAA. When the two groups of patients were compared we found that there was an higher percentage of perineal or anal disease (40.0% vs 2.2%; p <0.001), of extraintestinal manifestations of inflammatory bowel disease (IBD) (40.0% vs 3.3%, p <0.001), and of leak of the IPAA (40.0% vs 11.1%; p <0.05) in the group with fistula vs the group without fistula. CONCLUSIONS: A direct link with the leak of the IPAA appears in all the early fistulas, while the cryptoglandular infection was suggested as a possible cause of the late fistulas located below the IPAA; the association with the extraintestinal manifestations of IBD could show a correlation between the fistulas and an higher specific activity of the underlying chronic inflammatory disease.

Long-term survival after transarterial chemoembolization for hepatocellular carcinoma.

Hepatocellular carcinoma is a main challenge in oncologic care. Surgery is the mainstay of treatment. Transarterial chemoembolization is the most widely used palliative treatment for hepatocellular carcinoma. The Authors present a case report of a 61-year old man with hepatocellular carcinoma, belonging to Child-Pugh class A. The advanced age and the previous history of bladder carcinoma made the patient not suitable for liver transplantation. The patient refused hepatic resection so that transarterial chemoembolization was proposed. During 14-year follow-up there was intrahepatic progression of the tumor after the first treatment, followed by reduction in size and number of the lesions after subsequent treatments. In spite of the ominous prognosis of hepatocellular carcinoma, in this case-report transarterial chemoembolization allowed us to achieve a unique long-term survival.

[Mesh infection in inguinal hernioplasty by Streptococcus dysgalactiae subspecies equisimilis. Case report and review of the literature]. / Infezione da Streptococcus dysgalactiae subspecies equisimilis in ernioplastica inguinale. Caso clinico e revisione della letteratura.

INTRODUCTION: Mesh infection in inguinal herniography is usually caused by Staphilococcus aureus and Staphilcoccus epidermidis. Generally it obliges to prosthesis removal with hernia relapse and increase of social costs for the prolongation of hospitalization. CASE REPORT: A 60-year-old woman, obese, undergone 4 months before to left inguinal prosthetic herniorrhaphy complicated by infection of the surgical site which didn't require the explantation of the mesh, although determining an early hernia relapse. She is submitted by the authors to a surgical intervention for left groin hernia relapse with placement of a polypropylene monofilament fixed with prolene. Six hours after the operation she shows systemic symptoms and local signs of prosthesis infection. Cultural examination of the surgical wound secretion allows the identification of Streptococcus dysgalactiae subspecies equisimilis (SDSE). A therapy with Amoxicillin-Clavulanic Acid and Levofloxacine leads to resolution, in 10 weeks, of the infection. DISCUSSION: In our case the infection of the new mesh, appearing prematurely, has been probably favoured by obesity and operative time longer than 3 hours. Conservative treatment has been fulfilled by success for the elevated sensitivity of the SDSE bacterium to penicillin and fluoroquinolones. CONCLUSIONS: Recent epidemiologic studies have demonstrated an increase of infections caused by SDSE, which will probably gain clinical relevance in the next future relatively to surgical prosthetic hernioplasty. In all cases of infection the authors suggest cultural isolation of the casual germ and the execution of the antibiogram because the conservative medical treatment can avoid mesh removal with consequent elevated risk of hernia relapse.

[Gallbladder polypoid lesions. Three clinical cases with difficult diagnosis and literature review]. / Lesioni polipoidi della colecisti. Presentazione di tre casi clinici di "difficile" diagnosi e revisione della letteratura.

INTRODUCTION: Gallbladder polypoid lesions occur in 1.3%-6.9% of cases. The preoperative diagnosis between benign, malignant and potentially malignant lesions is difficult. Therefore it is not possible any. PATIENTS AND METHODS: The Authors describe three cases. The case 1 was a gallbladder diffuse adenomyomatosis; the ultrasound and the CT were of little help in defining preoperatively the nature and the gravity of the thickening. Case 2 was an adenomyomatosis of the fundus: the ultrasound examinations were not able to establish preoperatively lesion's nature, site and dimensions. In the case 3, ultrasounds showed polypoid lesions and calculi concrections not found in colecistectomy. DISCUSSION: The ultrasound is the most widely used diagnostic tool in the evaluation of gallbladder polypoid lesions; its accuracy is only 66%. CT, which has an accuracy level of 75%, must be carried out there is any possibility of malignant degeneration of the polyp. If doubts persist, a MR, 93% accuracy, is indicated. In selected cases, PET can be of further help. CONCLUSIONS: The preoperative diagnosis of the nature of gallbladder polypoid lesions is "difficult" and this justifies the lack of consensus on treatment. However, the adenoma-carcinoma sequence, widely discussed in literature, can justifies to the use of CT, MR, PET and surgical treatment after an ultrasound examination.

[A rare cause of acute abdomen: splenic infarction. Case report and review of the literature]. / Rara causa di addome acuto: l'infarto splenico. Caso clinico e revisione della letteratura.

INTRODUCTION: Splenic infarction is a rare cause of acute abdomen. It must be suspected in patient with hematologic diseases or thromboembolic conditions. The most common onset symptom is left-upper quadrant abdominal pain. Additional symptoms include fever and anemia. Laboratory may show elevated white blood cell and platelet counts. CASE REPORT: A 97-year-old female with a past history of atrial fibrillation presented with left-upper quadrant abdominal pain and fever since 20 days. Laboratory showed elevated white blood cell and platelet counts, increased C-reactive protein and lactate dehydrogenase. Both ultrasonographic and tomographic scans showed a large hypodense area of the spleen. The patient received intravenous antibiotic therapy, which led to significant clinical improvement with discharge 16 days after admission. DISCUSSION: The diagnosis of splenic infarction is based both on clinical presentation and imaging studies. Angio-computed tomography is the diagnostic procedure of choice. Ultrasonography and conventional radiology are useful in the differential diagnosis with other abdominal and thoracic diseases mimicking splenic infarction. In our case the management was conservative, because the patient was hemodynamically stable and antibiotic therapy could control the sepsis. Moreover, advanced age and poor cardiac and respiratory conditions contraindicated surgery. CONCLUSIONS: In our case splenic infarction was probably due to a thromboembolic event secondary to atrial fibrillation. In accordance with the literature, we suggest initial conservative therapy. Surgery is indicated only in the presence of complications.

Endoscopic sphincterotomy of the major duodenal papilla in acute relapsing pancreatitis associated with pancreas divisum: a case report.

We report a case of acute relapsing pancreatitis associated with pancreas divisum, who underwent major papilla sphincterotomy after failed minor papilla cannulation. Long-term results were satisfactory. The possible explanations of the efficacy of major papilla endoscopic resection in this particular case are discussed.

Effects of hemoperfusion with an immobilized polymyxin-B fiber column on cytokine plasma levels in patients with abdominal sepsis.

AIM: The beneficial role of hemofiltration with immobilized polymyxin-B fiber (PMX) columns in sepsis, especially sepsis due to gram-negative bacteria, has previously been emphasized. Although the efficacy of PMX-B fiber-mediated hemofiltration in reducing plasma levels of cytokines has been reported, other studies did not confirm this observation. Here we report the effects of PMX-B fiber-mediated hemofiltration on outcome and cytokine plasma levels in patients with abdominal sepsis. METHODS: Twelve consecutive patients admitted to the Intensive Care Unit (October 2006-December 2007) for severe sepsis/septic shock from abdominal infection were treated with standard therapy and 2 cycles of hemofiltration with PMX cartridges. Clinical data and plasma levels of IL-6, IL-10 and TNF-a were measured 24 hours before and after PMX treatment. RESULTS: Plasma concentrations (pg/mL) of IL-6, IL-10 and TNF-a were significantly lower after hemofiltration with a PMX fiber column (279.9+/-69.2 vs. 130.9+/-18.4, 166.4+/-36.7 vs. 45.5+/-12.2, 83.1+/-13.5 vs. 23.9+/-5.1 pg/mL, respectively; P<0.05). After treatment, patients required lower doses of norepinephrine (0.3+/-0.1 vs. 0.8+/-0.1 mg/kg/min) and reduced lactate levels, recovery of respiratory function and improved Simplified Organ Failure Assessment (SOFA) scores. After 28 days, 6 patients (50%) had survived. Subgroup analysis demonstrated that survivors had higher IL-6 and lower IL-10 and TNF-a pre-treatment plasma levels (pg/mL) compared with deceased patients (324.4+/-41.1 vs.235.3+/-38.4; 98.5+/-16.1 vs. 234.3+/-48.6, 44.5+/-9.0 vs.121.6+/-52.3 pg/mL, respectively; P<0.05). No adverse events imputable to the treatment were recorded. CONCLUSION: Hemofiltration with a PMX fiber column was able to reduce plasma levels of IL-6, IL-10 and TNF-a, especially in patients surviving at 28 days. Use of the technique was associated with lower norepinephrine support and an increased PaO2/FiO2 ratio.

[Unusual cause of acute abdomen in adult patient: gallstone ileus]. / Insolita causa di addome acuto in paziente adulto: l'ileo biliare.

INTRODUCTION: Gallstone ileus is a rare complication of cholecystolithiasis. It causes 1-3% of the mechanical obstructions of the small bowel. It often affects patients between 63 and 85 years old. Pre-operative diagnosis is usually delayed 1-10 days because there is not a specific symptomatology. CASE REPORT: The authors report the case of a 50 year-old man with diagnosis of mechanical obstruction of the small bowel caused by a voluminous gallstone. Ileal occlusion was showed by CT. The patient underwent to one-stage emergency surgery with enterolithotomy, cholecystectomy and duodenal fistula repair. Patient's recovery was regular and he was discharged fourteen days after surgery. DISCUSSION: In our case gallstone ileus was diagnosed with a delay of 5 days. Ultrasonography was not able to show the gallbladder. Diagnosis was made by CT, which is the diagnostic gold standard. CONCLUSION: Patient's performance status influences surgical strategy. In our experience, the patient underwent one-stage surgery because he was considered at low risk. Instead staged procedure with enterolithotomy and delayed cholecystectomy and fistula repair, is performed only in patients at high risk.