Prophylactic intra-abdominal drainage following colorectal anastomoses. A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Clinically evident Anastomotic Leakage (AL) remains one of the most feared complications after colorectal resections with primary anastomosis. The primary aim of this systematic review and meta-analysis was to determine whether Prophylactic Drainage (PD) after colorectal anastomoses confers any advantage in the prevention and management of AL. METHODS: Systematic literature search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE databases for randomized studies comparing clinical outcomes of patients with Drained (D) or Undrained (UD) colorectal anastomoses performed for any cause. RESULTS: Four randomized controlled trials comparing D and UD patients undergoing colorectal resections with primary anastomosis were included for quantitative synthesis. In total, 1120 patients were allocated to group D (n = 566) or group UD (n = 554). The clinical AL rate was 8.5% in the D group and 7.6% in the UD group, with no statistically significant difference (P = 0.57). Rates of radiological AL (D: 4.2% versus UD: 5.6%; P = 0.42), mortality (D: 3.6% versus UD: 4.4%; P = 0.63), overall morbidity (D: 16.6% versus UD: 18.6%, P = 0.38), wound infection (D: 5.4% versus UD: 5.3%, P = 0.95), pelvic sepsis (D: 9.7% versus UD: 10.5%, P = 0.75), postoperative bowel obstruction (D: 9.9% versus UD: 6.9%, P = 0.07), and reintervention for abdominal complication (D: 9.1% versus UD: 7.9%, P = 0.48) were equivalent between the two groups. CONCLUSIONS: The present meta-analysis of randomized controlled trials investigating the value of PD following colorectal anastomoses does not support the routine use of prophylactic drains.

Syncope with Surprise: An Unexpected Finding of Huge Gastric Diverticulum.

A gastric diverticulum is a pouch protruding from the gastric wall. The vague long clinical history ranging between dyspepsia, postprandial fullness, and upper gastrointestinal bleeding makes this condition a diagnostic challenge. We present a case of large gastric diverticulum that has been diagnosed during clinical investigations for suspected cardiovascular issues in a patient admitted at the medical ward for syncope. A 51-year-old man presented to the medical department due to a syncopal episode occurring while he was resting on the beach after having his lunch, with concomitant vague epimesogastric gravative pain without any other symptom. A diagnosis of neuromediated syncopal episode was made by the cardiologist. Due to the referred epimesogastric pain, an abdominal ultrasound scan was carried out, showing perisplenic fluid. A CT scan of the abdomen was performed to exclude splenic lesions. The CT scan revealed a large diverticulum protruding from the gastric fundus. The upper gastrointestinal endoscopy visualized a large diverticular neck situated in the posterior wall of the gastric fundus, partially filled by undigested food. The patient underwent surgery, with an uneventful postoperative course. Histologic examination showed a full-thickness stomach specimen, indicative of a congenital diverticulum. At the 2nd month of follow-up, the patient was asymptomatic.

Histologic considerations about a rare case of recurrent incisional hernia on McBurney incision.

AIM: Incisional hernias are often related to longitudinal or transverse laparotomy with an incidence that rises from to 2 to 23 %. The oblique incision often used to surgically treat acute appendicitis has little probability to develop incisional hernia with an estimated incidence less than 2%. Some series report 0.1 - 0.9% of it. Anatomic, physiologic and histologic factors have been implicated in herniation development, such as intra-abdominal pressure or alteration on tissue components; many different risk factors can be taken into account to justify this rare condition such as female gender, diabetes, peritonitis, abscess or appendiceal phlegmon as the cause of the first operation, wound infection, seroma, use of cutgut to suture aponeurosis, interrupted suture to the aponeurotic layer. MATERIAL OF STUDY: We present the rare case of young man who underwent surgical operation of acute appendicitis. Mc Burney incision was performed. Successively he underwent re-operation for incisional hernia developed upon McBurney incision and then "recurrence" of the same one. DISCUSSION AND CONCLUSION: Histological analysis of scar tissue was done. Alteration on histological pattern protein expression was discovered.

Liver hydatidosis: reasoned indications of surgical treatment. Comparison between conservative and radical techniques Retrospective study.

Liver hydatidosis is a focal benign parasitic disease that still cause high rate of morbidity particularly in the Mediterranean area. A retrospective study comparing conservative and radical techniques in a General and Urgent Surgery operative unit was carried out in order to find signs of its surgical treatment. A total of 50 patients, 24 men and 26 women, who experienced a surgical treatment from 2000 to 2011, participated, and through the Fisher's Exact Test characteristics of the cysts, post-operative complications and relapse were compared. As a result, 29 patients undertook conservative surgery, while 21 radical surgery. There was a relationship between characteristics of the cysts and the technique chosen, (p<0.001). Likewise, whenever the diameter was smaller than 10cm or localized in the left lobe a radical technique was used. Conversely, a conservative technique was used when the diameter was bigger than 10 cm or they were localized in the right lobe or complicated by intra-biliary or intra-peritoneal rupture as well as in contiguity with major vascular and biliary structures. In this regard, while the post-operative morbidity was related to the conservative techniques (p<0.004), the relapses tended to not be related to any techniques in our case (p<0.14). In conclusion, in a non hepato-bilio-pancreatic center a radical surgery including liver resection is suggested for left lobe's cysts, while a conservative technique tends to be more effective for right lobe's cysts mainly if complex. Consequently, patients with complicated presentation could explain why conservative treatment causes higher rate of morbidity.

Colonic stenting in acutely obstructed left-sided colon cancer Clinical evaluation and cost analysis.

AIM: This retrospective study aims to evaluate clinical and cost effectiveness of colonic stenting as a bridge to surgery and as a palliative treatment in acutely obstructed left-sided colon cancer. MATERIAL AND METHODS: Onehundred fortyfour patients were collected between 2006 and 2012, with acute left-sided malignant colonic obstruction with no evidence of peritonitis: 96 patients underwent surgical treatment, 48 underwent decompressive stenting. For the stenting we used self-expandable metallic stent in nitinol. RESULTS: Patients who had successful colonic stenting were 40, 8 underwent elective surgery within 10 days, 32 decompression stenting had only palliative intent. in 8/48 patients subjected to stenting decompression there was a technical failure (16%) and underwent emergency surgery. 40 patients had follow-up. at the time of observation 36 patients had a functioning stent, within 10 days 8 underwent elective definitive colonic resection with primary anastomosis trought videolaparoscopic thecnical, 4 (10%) had major complications and underwent emergency surgery. no patient of 40 in the stenting group required defunctioning stomas compared to 38 of 96 in emergency surgery group. we also compared the cost of decompressive stenting and emergency surgery treatment in acutely obstructed left-sided colon cancer referring to average cost of drg (1 and 2 code t-student test). the comparison of the average costs between decompressive stenting and emergency surgery was performed in the group of patients underwent palliative treatment separately from ones underwent radical treatment. CONCLUSION: Colonic stenting followed by elective surgery may be safer and cost-effective, comparing to emergency surgery for left-sided malignant colonic obstruction. KEY WORDS: Bowel obstruction, Colonic cancer, Colonic stenting.

A rare case of abdominal cocoon.

AIM: Abdominal cocoon is a rare cause of intestinal obstruction usually diagnosed incidentally at laparotomy. It manifests by forming a membrane that typically encases the small bowel loops, leading to mechanical obstruction. Preoperative diagnosis is difficult. The etiology of this condition is not well understood; however, it is a form of chronic irritation and inflammation. METHOD: A 33 years old male, from Bangladesh, presented to our emergency department complaining of abdominal pain, nausea, and vomiting. CT abdomen shows a picture of intestinal obstruction at the level of the small intestine. Intraoperative findings showed encapsulation of small bowel by a dense whitish membrane as a cocoon. Histological examination showed a granulomatous peritonitis and Ascaris Lumbricoides in the bowel resected. RESULTS AND CONCLUSIONS: The preoperative diagnosis of abdominal cocoon is difficult and hence, the diagnosis is usually confirmed by laparotomy. Surgery remains the cornerstone in the management of abdominal cocoon. The pathogenesis of abdominal cocoon remains elusive and has been associated with several conditions. The initial diagnosis of our patient was bowel obstruction from cocoon syndrome (CT and intraoperative findings) probably primitive, and only histologically proved granulomatous peritonitis associated with the presence of the parasite.

Adult idiopathic intussusception: a case report and review of the literature.

Adult intussusception is a rare condition. Most of the cases are due to an organic lesion and unlike the incidence in children idiopathic forms are really exceptional, occurring at a rate of 5% of all cases. Whereas in children a main cause is seldom found, adult intussusception is usually characterised by the presence of a leading intraluminal benign or malignant lesion. The authors report their experience with a clinical case of ileocolic intussusception occurring in an 28-year-old white male. In spite of the patient's age, the clinical presentation was very typical with the classic triad of abdominal pain, blood per rectum and a palpable mass. Diagnostic tools, namely US and TC scan, together with colonoscopy confirmed the physical examination, so that surgery was initiated with a definite diagnosis of intussusception. A large polyp or a lymphoma were considered the possible leading causes. After right hemicolectomy, pathology revealed that there was no organic lesion and the bulging mass was caused only by oedema and haemorrhagic infiltration of the invaginated loop. The patient had been on antipsychotic drugs for several months and the possible explanation of the pathology was linked to altered peristalsis induced by the pharmacological agents he was taking. The authors compare their experience with the data reported in the literature, evaluating in particular the incidence, pathology, clinical presentation, diagnosis and treatment of adult intussusception.