Impact of Preoperative Three-Dimensional Endoanal Ultrasound on the Surgical Outcome of Primary Fistula in Ano. A Multi-Center Observational Study of 253 Patients.

PURPOSE: To evaluate the impact of preoperative three-dimensional endoanal ultrasound (3D-EAUS) on the clinical outcome of anal fistula surgery. METHODS: The research consisted of multi-center retrospective case-control study including 253 consecutive adult patients undergoing surgery for confirmed or suspected primary fistula in ano who had undergone preoperative 3D-EAUS evaluation between January 2011 and January 2021. Main outcome measures were the concordance (K value) between ultrasound results and surgery in the identification of fistulas internal openings, primary tracts and secondary extensions and the 6 and 12 months success rate in patients with concordant and discordant findings. RESULTS: A good agreement in the identification of the main fistulas characteristics between ultrasound results and operative findings was found. A significant difference (P < .0001; Fisher's exact test) in the success rate was found between patients with concordant and discordant ultrasound results and operative findings in identification or location of internal opening. Particularly, all the 11 (4.8%) patients with discordant results experimented a failure of the surgical procedure at 6 months follow-up. At re-operation, the shift from discordant to concordant results was associated with an 81.8% 12 months success-rate. CONCLUSION: The three-dimensional endoanal ultrasound preoperative evaluation may have a relevant impact on the outcome of a defined group of patients undergoing surgery for anal fistula, since the careful evaluation of ultrasound results could simplify the internal orifice intra-operative detection and improve the success rate.

Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European survey.

BACKGROUND: A retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts). METHODS: Eight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62%). In 175/313 patients, 55.9% underwent MGB/OAGB, while in 138/313 patients, 44.1% received SG between January 2006 and December 2014. RESULTS: Two hundred six out of 313 (63.7 %) pts reached 1 year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1 ± 6.6, and the mean BMI for SG pts was 35.9 ± 5.9 (p < 0.001). Eighty-two out of 96 (85.4%) MGB/OAGB pts vs. 67/110 (60.9%) SG pts are in remission (p < 0.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR) = 0.623, 95% confidence interval (CI) 0.419-0.925, p = 0.01], preoperative consumption of insulin or oral antidiabetic agents (OR = 0.256, 95% CI 0.137-0.478, p = <0.001), and T2DM duration >10 years (OR = 0.752, 95% CI 0.512-0.976, p = 0.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (OR = 3.888, 95% CI 1.654-9.143, p = 0.002) of diabetes remission. CONCLUSIONS: A significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12 months have been identified.

[Intestinal reconstruction after dehiscence of a jejunal suture in a patient submitted to aorto-enteric fistula repair: a case report]. / Ricostruzione intestinale dopo deiscenza di sutura digiunale in paziente sottoposto a riparazione di fistola aorto-enterica: case report.

Aorto-enteric fistulas are serious complications of aortic surgery that require swift, effective surgical intervention. We report a case of a secondary aortoenteric fistula treated with prosthesis replacement and an intestinal suture subsequently complicated by the dehiscence of the previously constructed anastomosis. We opted for reconstruction re-intervention, closing the intestinal lesion by means of a mechanical suture above the jejunal dehiscence, making a side-to-end jejuno-jejunal Roux anastomosis and an end-to-side anastomosis at the base of the loop. The operation was completed by performing a gastrostomy and transforming the fistula into a jejunostomy. This intervention enabled us to discharge the patient in good general condition after 30 days.

Clinical symptoms of intestinal vascular disorders.

Despite advances made in the diagnostic and therapeutic field, acute intestinal ischemia remains a highly lethal condition. This is related to the variability of symptoms and the absence of typical laboratory alterations in early stage.

[Our experience in the management of patients with Mirizzi syndrome]. / Orlentamenti attuali nel trattamento della sindrome di Mirizzi. Nostra esperienza.

The authors report their experience in the management of patients with Mirizzi Syndrome (MS) admitted, over a period of 15 years, at the General Surgery of Emergency Department of Cardarelli Hospital, Naples, Italy. All patients were admitted and surgically treated in emergency save for one. Out of 12 patients, cholecystectomy was performed in 7 cases. In others 5 patients, with cholecystocholedochal fistula, cholecystectomy with positionig of T-Tube was performed in 4 cases (MS-II); finally, 1 patient with MS type III undewrwent choledochojejunostomy. According to literature, the diagnostic protocol included abdominal ultrasonography and CT scan of the abdomen for all patients; in one case, a cholangio-MRI was performed to clarify the diagnosis. The preoperative diagnosis is essential to reduce risk of iatrogenic injuries. The cholangio-MRI, used to this extent, clarifies the site of obstruction, shows the anatomy of the biliary tree and allows to make all the possible differential diagnoses in order to exclude the presence of biliary tumors before surgery. The intraoperative cholangiography remains mandatory to clarify the anatomy of the biliary tree. In the cases we have treated, ERCP was never performed. We believe that ERCP has limited indications and unsatisfactory outcomes for both diagnosis and treatment of MS. Pathological examination of the fresh-frozen surgical specimens was always performed intraoperatively to exclude the presence of concomitant cancer of the gallbladder. The traditional treatment of patients with MS is surgery, as confirmed by our experience. We perform cholecystectomy for MS type I and cholecystectomy with direct repair of the biliary fistula over aT tube for MS type II. Patients with MS type III usually undergo a tailored operation based on the intraoperative findings, while choledochojejunostomy is mandatory for patients with MS type IV. Laparoscopic surgery is indicated only for MS type I and II. It seems to carry a higher risk for the patient and we do not use this approach in the emergency settings.

[Conservative treatment of the digestive fistulas: personal experience]. / Trattamento conservativo delle fistole digestive: nostra esperienza.

OBJECTIVE: The authors, thanks to experience obtained in an Unit for the treatment of digestive fistulas, discuss the possibility of a conservative treatment for the anastomotic fistulas. MATERIAL AND METHODS: From 2000 to 2003 were treated thirty-five patients with post-anastomotic gastroenteric fistulas marked according to their localization, way end output (51.5% high, 42.8% moderate and 5.7% low). The treatment is based on an aspiration system, sometimes integrated with an irrigation system. A semi-permeable barrier was created over the fistula by vacuum packing a synthetic, hydrophobic, polymer covered with a self-adherent surgical sheet. This system create a vacuum chamber equipped with a subathmospheric pressures between 262.2 and 337.5 mmHg (350-450 mmbar), integrated with a continuous irrigation using antibiotic solutions or 3% lactic acid. RESULTS: The AA. obtained the resolution in 30 patients (85.7%), 3 patients needs the surgery (8.6%), 2 died, one for sepsis and the other one for malnutrition. The mean time for the closure was 45 days (from 20 to 90). A part of digestive external fistulas goes to spontaneous resolution so comes the idea that the creation of particular condition is the basis of their closure.