Spontaneous rupture of umbilical hernia in end stage liver disease patient: injection of fibrin glue as a temporary solution.

BACKGROUND: Umbilical hernia is a common disease, which occurs in 20% of cirrhotic patients in the presence of persistent ascites. A rare but dangerous complication of this disease in end stage liver patient is a spontaneous rupture of umbilical hernia with ascitic fluid leaking. Up to date there is no general consensus on its most appropriate treatment. CASE REPORT: A 60 years-old male patient, with Child Pugh C and Meld score of 18 end stage liver disease, came to our observation for a spontaneous minimal rupture of his long lasting 5 cm umbilical hernia with ascitic fluid leaking. A medical therapy was undertaken aiming to manage the ascites and a temporary conservative therapy, with fibrin glue injection, was performed to solve the hernia ulceration, delaying the surgical repair after 20 days, when he underwent to a surgical repair with the positioning of a on lay mesh. At 12 month follow up we did not observe any recurrence. CONCLUSIONS: Spontaneous rupture of umbilical hernia is a rare but life threatening complication of umbilical hernia in cirrhotic patient with refractory ascites. Even if a general consensus on its management is lacking, a conservative therapy with glue injection, appears feasible and effective, with low risk and representing a bridge therapy to surgery, to treat the ascitic leak and allow the clinical optimization of the patient.

Lumevis ™: a new medical device to prepare patients for esophagogastroduodenoscopy. Experimental clinical study.

BACKGROUND: Esophagogastroduodenoscopy (EGDS) is the gold standard exam for upper gastrointestinal diseases. EGDS is very important in Early Gastric Cancer diagnosis and treatment but it is an operator-dependent exam and there are lots of factors that reduce its visibility (mucus, bubbles and foam). AIM: The aim of our study is to evaluate if the use of Lumevis™ improves mucosa visualization during EGDS without increasing the examination time and complications' rate and comparing the differences in patients prepared with water or no intervention. MATERIALS AND METHODS: we recruited 50 patients from 01/08/2020 to 31/08/2020 who came to our observation for epigastric pain, dyspepsia and gastroesophageal reflux (GERD). For each patient we evaluate the satisfaction of the procedure, vision quality, EGDS duration and the presence of bubbles following the administration of: nothing (group 1); 50 ml of water alone (W) (group 2); W + simethicone (S) 150 mg+N-acetylcysteine (NAC) 250 mg+10% acetic acid 2.5 ml (group 3); W+S 100 mg + NAC 300 mg + 10% acetic acid 2 ml (group 4); W + S 100 mg + NAC 200 mg + 10% acetic acid 1.5 ml (group 5). RESULTS: Our results suggest that the lesion detection rate improves with the use of simethicone, acetylcysteine and acetic acid prior to EGDS, although this needs to be studied prospectively. CONCLUSIONS: Lumevis™ is proposed as a new product in the routine preparation of all patients who have to undergo an EGDS, raising the level in the quality of the exam.

Sustainability evaluation of Sicily's lemon and orange production: an energy, economic and environmental analysis.

The island of Sicily has a long standing tradition in citrus growing. We evaluated the sustainability of orange and lemon orchards, under organic and conventional farming, using an energy, environmental and economic analysis of the whole production cycle by using a life cycle assessment approach. These orchard systems differ only in terms of a few of the inputs used and the duration of the various agricultural operations. The quantity of energy consumption in the production cycle was calculated by multiplying the quantity of inputs used by the energy conversion factors drawn from the literature. The production costs were calculated considering all internal costs, including equipment, materials, wages, and costs of working capital. The performance of the two systems (organic and conventional), was compared over a period of fifty years. The results, based on unit surface area (ha) production, prove the stronger sustainability of the organic over the conventional system, both in terms of energy consumption and environmental impact, especially for lemons. The sustainability of organic systems is mainly due to the use of environmentally friendly crop inputs (fertilizers, not use of synthetic products, etc.). In terms of production costs, the conventional management systems were more expensive, and both systems were heavily influenced by wages. In terms of kg of final product, the organic production system showed better environmental and energy performances.

In vivo liver expression of TLR2, TLR3 and TLR7 in chronic hepatitis C.

The role of innate immune response mediated by Toll-like receptors in HCV infection, is not yet well understood and there is a lack of data regarding liver tissue expression of these molecules in chronic hepatitis C (CHC). Our study is aimed to investigate ex vivo, liver expression of TLR2, TLR3 and TLR7, which are more involved in the immune-pathogenesis of CHC, and to explore possible correlations with features of disease. We obtained liver biopsies and collected peripheral blood mononuclear cells (PBMC) from 23 consecutive patients with CHC and from 6 patients of control, without liver disease, undergoing surgery for cholecystectomy. The levels of TLRs mRNA in the samples were determined using a real-time reverse transcription quantitative PCR (RT-qPCR). We found a significant high expression of TLR3 in the liver of CHC patients respect to controls (also higher than expression in the PBMC). Conversely no differences emerged in the TLR2 and TLR7 levels between cases and controls. Also we found a correlation of TLR2 and TLR7 levels with the grade of necro-inflammation in the liver. Furthermore TLR7 hepatic levels resulted related to a more advanced stage of liver fibrosis. Ours is the first study to provide data on tissue expression of TLRs during chronic hepatitis C and we believe that it could lead to a better understanding of the role of these molecules in the HCV-mediated liver damage.

Giant condyloma acuminatum quickly growing: case report.

BACKGROUND: Giant Condyloma Acuminatum (GCA) is a rare, slow growing, large cauliflower tumor of the penile foreskin and perianal region with benign histologic appearance but high propensity for local invasion and recurrences. GCA is associated with Human Papilloma Virus (HPV) types 6 and 11 and it also has considerable risk of neoplastic transformation into fully invasive squamous cell carcinoma into about 5 years. OBJECTIVE: Because of the rarity of perianal GCA, to date there is no general agreement on the best method for treatment. We wanted to know if surgical approach only was a good method to treat our case. CASE REPORT: A 28 years old man, HIV-negative, with a 4 years history of perianal GCA quickly growing underwent full tickness local excision at least 0,7 cm margin of normal tissue with skin grafting taken from the thighs. Fecal contamination was avoided by diet and loperamide per os. At two years follow-up no recurrence was detected. CONCLUSION: Surgical approach with full tickness excision and immediate skin-grafting and regular follow-up demonstrated effective to treat GCA and to minimize disease recurrence.

Fissurectomy combined with anoplasty and injection of botulinum toxin in treatment of anterior chronic anal fissure with hypertonia of internal anal sphincter: a pilot study.

BACKGROUND: In patients affected by anterior chronic anal fissure (CAAF) with hypertonia of the internal anal sphincter (IAS), the role of IAS hypertonia remains unclear. The aim of this study was to evaluate the efficacy of fissurectomy combined with advancement flap and IAS injection of botulinum toxin in healing the CAAF with hypertonia of IAS resistant to medical therapy. METHODS: Ten consecutive patients were enrolled. Anorectal manometry was performed preoperatively and at 6 months. CAAF with hypertonia was defined as those associated with maximum resting pressure (MRP) values higher than 85 mmHg. All patients underwent fissurectomy and anoplasty with advancement skin flap combined with the intrasphincter injection of 30 UI of botulinum toxin. Complete healing, MRP changes, relief of symptoms and immediate and long-term complications were recorded. RESULTS: Complete healing was observed in all patients within 30 days of the operation. The intensity and duration of pain post-defecation was reduced significantly starting from the first defecation. In all subjects, the preoperative MRP values were significantly reduced at 6 months. One month after surgery, three patients reported anal incontinence, two of them had complained preoperatively. The only postoperative complications were minor. CONCLUSIONS: Fissurectomy combined with advancement flap and intrasphincter injection of botulinum toxin results in complete healing, significant MRP reduction and full relief of symptom in all patients, thus it represents a valid procedure in preventing the occurrence of anal incontinence.

Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females.

AIM: Lateral internal sphincterotomy is considered the surgical treatment of choice for chronic anal fissure after failure of medical therapy but it risks continence. The aim of the study was to evaluate fissurectomy with advancement flap for anterior chronic anal fissure (CAAF) resistant to medical therapy. METHOD: Sixteen women with CAAF without hypertonia of the internal anal sphincter, unresponsive to previous medical treatment, were included in the study. Absence of hypertonia was defined as a maximum anal resting pressure (MRP) of less than 85 mmHg. All patients underwent fissurectomy with an advancement skin flap. RESULTS: Complete healing occurred in all patients within 30 days. The intensity and the duration of pain after defecation reduced from the first postoperative defecation. MRP before surgery and at 6 months showed no significant difference. At 1 month, four patients experienced a continence disturbance, two of whom had it preoperatively. At 12 months, two (12.5%) patients continued to experience a continence disturbance. CONCLUSION: Fissurectomy with skin advancement flap resulted in complete healing and full relief of symptoms in all patients. There was a low incidence of continence disturbance.

[Bilateral testicular lymphoma. Case report]. / Linfoma primitivo testicolare bilaterale: a proposito di un caso clinico.

A case of bilateral testicular lymphoma with involvement of skin and oropharynx was described. After a review of literature, the Authors underline the clinical features focusing the diagnostic approaches and the therapeutics options.

Randomized clinical trial of botulinum toxin injection for pain relief in patients with thrombosed external haemorrhoids.

BACKGROUND: Thrombosed external haemorrhoids are one of the most frequent anorectal emergencies. They are associated with swelling and intense pain. Internal sphincter hypertonicity plays a role in the aetiology of the pain. This study evaluated the efficacy and safety of an intrasphincteric injection of botulinum toxin for pain relief in patients with thrombosed external haemorrhoids. METHODS: Thirty patients with thrombosed external haemorrhoids who refused surgical operation were randomized into two groups. Patients received an intrasphincteric injection of either 0.6 ml saline or 0.6 ml of a solution containing 30 units botulinum toxin. Anorectal manometry was performed before treatment and 5 days afterwards. RESULTS: After 5 days of treatment, the maximum resting pressure fell in both groups, but was significantly lower in the botulinum toxin group (P = 0.004). Pain intensity was significantly reduced within 24 h of botulinum toxin treatment (P < 0.001), but only after 1 week in the placebo group (P = 0.019). CONCLUSION: A single injection of botulinum toxin into the anal sphincter seems to be effective in rapidly controlling the pain associated with thrombosed external haemorrhoids, and could represent an effective conservative treatment for this condition. REGISTRATION NUMBER: NCT00717782 (http://www.clinicaltrials.gov).

Impact of different texture of polypropylene mesh on the inflammatory response.

Over the past decade, hernia surgery has undergone a considerable transformation with the use of prosthetic materials. The most used polypropylene meshes induce a rapid acute inflammatory response followed by chronic foreign body reaction. Many factors influence this response such as density, size, physical characteristics, different texture and porosity of each biomaterial. The aim of this study is to assess whether the implant of monofilament or multifilament meshes, in the inguinal hernioplasty, determine a different inflammatory response. Thirty-two male patients were included in the study and were randomly divided into two groups. In the first group (MO) inguinal hernioplasty was performed using monofilament polypropylene mesh, while in the second one (MU) multifilament prosthesis was used. Peripheral venous blood samples were collected 24 hours before surgery and then 6, 24, 48 and 168 hours post-operatively. Modifications in leukocyte count, C-reactive protein (CRP), alpha-1 antitrypsin (alpha1-AT), interleukin (IL)-1, IL-6, IL-1 ra and IL-10 serum levels were recorded at all sampling times. We present evidence that serum levels of CRP, (alpha1-AT), leukocytes and cytokines were significantly increased post-operatively in both groups, returning to basal values 168 hours afterwards. In particular, the production of all pro-inflammatory mediators was higher in the MU group, whereas the anti-inflammatory cytokine (IL-10, IL-1ra) production was higher in MO patients. Our results indicate that polypropylene multifilament mesh allows a higher intense acute inflammatory response as compared to monofilament mesh implantation.

Use of fibrin glue in the treatment of pilonidal sinus disease: a pilot study.

BACKGROUND: Pilonidal sinus (PS) disease of the sacrococcigeal region is an acquired condition resulting from penetration of shed hair shafts through the skin. Different types of operations have been described in the letterature. More recently fibrin glue has been used with succesfull. Aim of this study was to assess the effectiveness of fibrin glue for the treatment of pilonidal sinus. PATIENTS AND METHODS: Eight patients age ranged 21,8 +/- 6,5 affected by PS disease of sacrococcigeal region were included in this study. All patients undergoing surgical operation under local anaesthesia. Following administration of 1% methylene blue through the main opening, a small vertical elliptical incision is maked including the entire sinus opening and an excision of PS was performed without entering the sinus cavity, removing a minimal amount of subcutaneous tissue. Afterwards the highly concentrated fibrin glue, containing 1,000 U/ml of thrombin was applied to cover the wound. Post-operative pain, analgesic consumption, duration of hospital stay, failure healing, the rate and time of recurrence, time to healing, time to return to work and post-operative complications were recordered. RESULTS: All patients expressed satisfaction with the procedure. Mean hospital stay was 5.4 +/- 2.1 hours. Healing was achieved after 25.8 +/- 13.2 days. The post-operative pain mean score was 3.8 +/- 2.1 in first day, 2,9 +/- 1,8 in third day and 1,3 +/- 0,8 in the seventh day. The mean analgesic consumption per week was 5,6 +/- 3,2 medications. Mean time to return to work was 5,3 +/- 2,1 days. CONCLUSION: The minimal excision of PS and application of fibrin glue is a non-invasive effective treatment, easy and simple to performe and not associated to recurrences. For these reasons this procedure in our opinion as the first line treatment for pilonidal sinus disease.

Production of cytokines at the operation site.

BACKGROUND AND AIM: Cytokines are part of a family of molecules involved in the initiation, control and termination of the events that occurs in wound healing process. Aim of this study was to evaluate the production of some cytokines [interleukin (IL)-6, IL-10, IL-1alpha, IL-1ra, interferon (IFN)-gamma] in the drainage wound fluid from patients undergoing incisional hernia repair. METHODS: Ten female patients with abdominal midline incisional hernia undergoing to surgical repair were included in this study. In all cases a closed suction drain was placed in the wound below the fascia and it was removed on the 4th postoperative day. Wound fluid was collected on the 1st, 2nd, 3rd and 4th day and its amount in each time was recorded. The production of IL-6, IL-10, IL-1alpha, IL-1ra and IFN-gamma were evaluated as quantity produced in 24 hour. RESULTS: In all patients the amount of drain fluid from surgical wound was highest on the 1st day after surgery, afterwards there is a significant reduction. The production of all cytokines evaluated was highest on the 1st day decreasing on the 2nd day except for IL-1alpha that not show any modification. The produciton of IL-1ra, IL-6, IL-1alpha and IL-10 was significantly reduced on the 3rd and 4th postoperative day in comparison with the respectively values recorded on the 1st day, whereas IFN-gamma levels were similar. CONCLUSIONS: The dosage of cytokines in the drain fluid led us to better evaluated the events that follow surgical wound and their analysis offers further information in the role of cytokines in healing process, with the goal to get supportive treatments to promote the best evolution.

[Jejunal cystic lymphangioma in adult with rapid growth]. / Linfangioma cistico del digiuno a rapida crescita nell'adulto.

Abdominal cystic lymphangiomas are a rare pathology that are related to abnormal development of the lymphatic system. They predominate in a children and are very uncommon in adults. Here the authors report a case of a cystic intra-abdominal lymphangioma in a 64-years old woman in which the cyst was situated in the mesentery of the jejuneum, with rapid growth. Ultrasonography, computed tomography and magnetic resonance imaging led us to evaluate a cystic characterizations and his site. Surgical excision remain the treatment of choice because we can establish an histologic diagnosis. Complete surgical excision of cyst, although it can be difficult, consent a definitive healing.

[Free perforation in Crohn's disease]. / La perforazione in peritoneo libera nella malattia di Crohn.

Free perforation in abdominal cavity in patients with Crohn's disease is a rare entity as attested from the data reported in the literature. It is a very dangerous event and requires a surgical urgency management. The Authors reported two cases of free perforation, in patients with Crohn' disease, undergoing surgical operation in urgency. Analyzing pathogenesis, difficulty in diagnosis making and therapeutic choices, they underline that CT is very useful in the diagnosis, while resection of the perforated intestinal tract represent the best surgical treatment.

Paraduodenal hernia: an uncommon cause of recurrent abdominal pain.

Internal abdominal hernias are a rare entity and may cause unexplained abdominal pain. This report concerns a 46 year old male patient, with a four year history of episodic colicky peristaltic abdominal pains, in whom a left paraduodenal hernia was found at surgical exploration after a negative diagnostic screening by ultrasound, CT and small bowel enema. Upon laparotomy the Authors found a left-sided paraduodenal hernia with an empty herniated sack. Repair of the hernial defect resulted in the complete and stable resolution of abdominal symptoms. The importance of considering paraduodenal hernias in the differential diagnosis of unexplained intermittent abdominal pain is discussed.

A painless treatment for patients undergoing Milligan-Morgan haemorrhoidectomy.

BACKGROUND: Postoperative pain associated with Milligan Morgan haemorrhoidectomy (MMH) remains problematic. Most patients complaint a severe pain on defecation and in the 1st postoperative week because of secondary infection and sphincter spasm. We studied the effect of metronidazole, lactulose and glyceryl-trinitrate on pain after MMH. METHOD: Thirty patients were randomly assigned to two groups. The 1st received a treatment with oral laxative (lactulose 66.7%) metronidazole and a topical glyceryl-trinitrate ointment at 0.2% both pre and postoperative; the 2nd received a placebo at the same dosage. The amount of pain in the 1st week and at the time of two defecation, postoperative analgesic requirement and time to return to normal activities were documented. RESULTS: A significant differences in the score pain on 2nd and 3rd day and on the 1st two defecation were observed among group. Analgesic consumption was highest in the placebo group. CONCLUSION: The treatment with lactulose, metronidazole and topic glyceryl-trinitrate in patients undergoing MMH, seems to reduce secondary pain and increase patients satisfaction and earlier return to work with improvement of cost and benefit.

[Milligan-Morgan haemorrhoidectomy with ultrasonic scalpel]. / L'emorroidectomia secondo Milligan-Morgan con bisturi ad ultrasuoni.

INTRODUCTION: Milligan-Morgan haemorrhoidectomy is considered the best treatment for hemorrhoidal disease. Although this, many patients complaint post-operative pain that remain the worse complication. For this reason different are the trials performed in order to reduce his intensity. In this report we want to evaluate if the use of ultrasonic scalpel to perform Milligan-Morgan hemorrhoidectomy, compared with conventional surgery, could reduce post-operative pain. MATERIALS AND METHODS: 30 patients with III and IV degree of haemorrhoids were included in this study and divided in two groups. In the first group Milligan-Morgan haemorrhoidectomy was performed with conventional instruments, while in the second group the some procedure was performed with ultrasonic scalpel. The duration of intervention, time hospitalization, the time to open alvus to stools, the time to return to normal activity, the complications, pain and the amount of analgesic consumption were evaluated. RESULTS: In the II group's patients, it was observed a reduced time to healing with reduced spread of necrosis and inflammatory pattern, associated with reduced post-operative pain and the lower analgesic consumption. CONCLUSIONS: The use of ultrasonic scalpel to perform Milligan-Morgan haemorrhoidectomy, compared with conventional instruments, reduce post-operative pain making a more short time to healing and a precocious time to return to normal activity. For this reason we believe that the use of ultrasonic scalpel, although a more elevated costs, seems to be advantageous.

[Leiomyoma of the nipple]. / Il leiomioma del capezzolo.

A case of 28 years woman with nipple's leiomyoma we report. Only 38 cases are reported in the literature. This neoplasm presents a difficult differential diagnosis with the remaining flogistic and neoplasm breast and nipple disease.

[Dieulafoy's ulcer: unusual cause of upper gastrointestinal tract. Our experience]. / L'ulcera di Dieulafoy: causa rara di emorragia del tratto gastroenterico superiore. Nostra esperienza.

OBJECTIVE: The authors report their experience about the endoscopic treatment of upper gastrointestinal bleeding from Dieulatoy's ulcer (non variceal bleeding). DESIGN: Report of 5 cases; evaluation of mortality and effectiveness of the treatment. SETTING: Operative Unit of General and Thoracic Surgery, Department of Surgical, Anatomical and Oncological Disciplines. Policlinico, University of Palermo. INTERVENTIONS: EGDS + sclerotherapy (emergency room) in all 5 patients. RESULTS: 80% successful (stop bleeding). CONCLUSIONS: Endoscopic sclerotherapy is choice treatment of upper gastrointestinal bleeding from Dieulafoy's ulcer, only in well experienced teams and rapidly.