Acute Pancreatitis during and after Pregnancy: A Review.

During pregnancy and in the post-partum period, several diseases may arise or become exacerbated. Acute pancreatitis is an inflammatory disease with an increasing incidence in Western countries. The incidence of acute pancreatitis during pregnancy is not different with respect to the general population, but this incidence increases in the first 2 years after delivery. Biliary sludge and stones are the most frequent aetiologies, followed by hypertriglyceridemia. Taking care of the mother and foetus through a potentially severe disease requires a team consisting of an obstetrician, a gastroenterologist, an anaesthesiologist, and a surgeon. It is necessary to monitor the health of the foetus/child and the mother during pregnancy, childbirth, and puerperium. The management of this care depends on the systemic and local complications, the severity of the acute pancreatitis, and the trimester of pregnancy. Some diagnostic tools and many drugs are not safe for foetuses, while interventional endoscopy and surgery have limitations and can only be used after an accurate evaluation of benefit/risk ratios. Despite these limitations, maternal mortality due to acute pancreatitis is low during pregnancy, mainly thanks to multidisciplinary approaches for these patients. A careful diet to prevent obesity, alcohol abstinence, routine serum triglyceride control, and breastfeeding for at least three months may prevent acute pancreatitis during and after pregnancy.

Breastfeeding in Prevention of Postpartum Acute Pancreatitis.

BACKGROUND: Acute pancreatitis (AP) caused by gallstones has an increased rate of incidence in young women in the 2 years postpartum. Middle-aged women with longer periods of breastfeeding have less hospitalization for gallbladder disease. AIM: To investigate whether breastfeeding or other variables may be associated with AP. METHODS: We conducted a population-based case-control study among all Sicilian women of childbearing age, and we identified all women who delivered (2013-2016) and had AP within 2 years postpartum. We reviewed their medical records, and for each case we matched four women of the same age (± 5 years), without AP. Univariate and multivariate logistic regression was used to estimate the odds ratios (OR) with their confidence intervals (CI) to assess associations between AP and clinical determinants. RESULTS: In the 74 women with AP and 298 controls at univariate analysis, > 6 months oral contraception history (p < 0.01; OR 3.30; 95% CI 1.33-8.16), previous biliary disease (p < 0.001; OR 5.90; 95% CI 1.98-17.57) and smoking (p = 0.035; OR 2.04; 95% CI 1.04-4.0) were predictors of AP; amenorrhea ≥ 3 months (p < 0.001; OR 0.34; 95% CI 0.19-0.59) and breastfeeding ≥ 3 months (p < 0.001; OR 0.07; 95% CI 0.03-0.14) were protective. At multivariate analysis, previous biliary disease (p = 0.011; OR 5.49; 95% CI 1.48-20.38) and breastfeeding ≥ 3 months (p < 0.001; OR 0.06; CI 95% 0.03-0.14) were associated with AP. CONCLUSIONS: Women who breastfeed for at least 3 months and do not have a history of biliary disorders have reduced risk of developing AP in the 2 years after delivery.

Acute Pancreatitis During and After Pregnancy: Incidence, Risk Factors, and Prognosis.

BACKGROUND: Acute pancreatitis may complicate pregnancy and both are associated with gallstones, but its incidence is not well known. AIMS: To validate hospital discharge records in diagnosing acute pancreatitis and gallstones and to evaluate acute pancreatitis incidence in non pregnant, pregnant and after delivery using hospital discharge records METHODS: We identified all hospital discharge records of hospitalized Sicilian women of childbearing age (2011-2016). We determined agreement between 300 hospital discharge records and hospital records in diagnosing acute pancreatitis and gallstones. Acute pancreatitis incidence, prognosis, and their relationship with age and gallstones were calculated in the three groups using hospital discharge records. RESULTS: There was 92% and 88% agreement in diagnosing acute pancreatitis and gallstones between hospital discharge and hospital records. In non pregnant, 1,564 of 7,236,863 women-years (21.61/100,000 person-years) developed acute pancreatitis. During pregnancy, 34 of 226,492 women-years developed acute pancreatitis (20.02/100,000 person-years). Postpartum acute pancreatitis incidence was higher than non pregnant, only in the first 2 years with the peak in the first semester (95.4/100,000 person-years). The increased incidence of postpartum acute pancreatitis was associated with gallstones in youngest women (gallstones acute pancreatitis in women below 20 years old versus non pregnant: rate ratios 16.61; 95% CI 8.40-32.87). CONCLUSIONS: Agreement in acute pancreatitis and gallstones diagnosis between hospital discharge and hospital records was accurate. Acute pancreatitis incidence was increased only in the first 2 years after delivery in young women with gallstones.

Recurrent sacrococcygeal pilonidal disease: the efficacy of minimal subcutaneous excision of the sinus and unroofing of pseudocystic cavity.

Patients undergoing surgery for recurrent pilonidal disease are at high risk of developing re-recurrence. The present prospective analysis was performed to evaluate the outcome for recurrent pilonidal disease treatment with a technique that provides a minimal subcutaneous excision of fistula and of the skin above the cyst, with secondary healing of wounds. METHODS: 48 consecutive patients with previous surgical excision and recurrent pilonidal disease underwent surgery from January 2009 to December 2016, under local anaesthesia. The age of the patients (42 males and 6 females) at the time of our observation was 28.5 ± 10.2 years, the BMI of 26.3 ± 6.8. The average number of interventions prior to our was 2.02 ± 1.14. RESULTS: The mean operative time was 18.2 ± 5.5 minutes. All patients were discharged 2 to 4 hours after surgery, with an average healing time of 22.8 ± 15.3 days. We recorded, in the follow-up period, only 4 relapses (8.32%), all retreated with the same surgical procedure and brought to complete healing. The results of the cosmetic questionnaire, which assessed patient satisfaction and contentment, showed that 96% of patients were completely satisfied and all patients recommended surgery to others. Kaplan-Meier analysis showed that in 7 years of follow-up, 85% of patients healed without recurrence. CONCLUSIONS: Our simple procedure appears to be safe and easily reproducible, allowing a high surgical success in the treatment of recurrent pilonidal disease. KEY EORDS: Excision, Healing, Recurrent sacrococcygeal pilonidal disease.

Umbilical hernioplasty in cirrhotic patients with ascites A case control study.

OBJECTIVE: Umbilical hernia is a very frequent pathology, and plastic with prosthetic material is the most frequently used surgical procedure currently used for its repair. In patients with cirrhosis in asciic phase, this pathology is particularly frequent, with a tendency to rapidly increase in size and to become symptomatic. In the past treatment with traditional surgery in cirrhotic patients was considered problematic and was viewed with reserve, and only recently is the surgical approach recommended also in these patients. This study is aimed to evaluate the feasibility and safety of open umbilical hernia plastic with prosthetic material in cirrhotic and ascitic patients. MATERIALS AND METHODS: Our case-control study was conducted on 35 male patients with ascitic phase liver cirrhosis and an equal number of non-cirrhotic patients, all suffering from uncomplicated but symptomatic umbilical hernia, treated surgically consecutively from March 2005 to March 2015. All patients underwent open umbilical hernioplasty with placement of a retromuscular pre-aponeurotic mesh. RESULTS: Of the 35 patients with liver cirrhosis, 20% were classified in Class C, according to Child-Pugh, 28.5% had a MELD score> 15. We have not shown any post-operative mortality. In general, minor complications were observed, more frequent in cirrhotic patients than in healthy controls (p = 0.0315). Among the aforementioned complications the most frequent were hematomas and wound infections, more frequent in cirrhotic patients in Class C according to Child- Pugh and with MELD score> 15 (p <0.005). CONCLUSIONS: Our study shows that umbilical hernia pathology in ascitic cirrhotic patients can be treated surgically with satisfactory results especially in Child-Pugh class A and B patients. The surgical approach of choice must, preferably, be the preferred prosthetic plastic after pre-operative optimization of the coagulation, nutritional and ascitic state. KEY WORDS: Ascites, Hernioplasty ,Liver cirrhosis; Umbilical hernia.

Inguinal hernioplasty in patients with cirrhosis and ascites: what preventive measures are needed for a safe procedure?

BACKGROUND: Inguinal hernioplasty in patients with LC and ascites has been long discouraged for the incidence of postoperative complications. The aim is to evaluate the appropriateness of this elective surgical procedure in patients with LC and ascites. METHODS: Thirty consecutive LC patients with ascites and affected by inguinal hernia (LC group), who underwent elective open inguinal hernioplasty with mesh placement, have been matched with the same number of patients non-LC (non-LC group) who underwent the same surgical procedure in the same period of time. All patients in LC group received a careful hepatological assessment and were classified according to the etiology of LC and to the Child's class. Patients of both groups received an antibiotic prophylaxis and were operated under local anesthesia. RESULTS: No significant complications were observed in any patients during surgery. The hospital stay was significantly longer in LC group. During the postoperative time, 4 inguinoscrotal hematoma appeared in LC group, of which 3 in class C (LC VS non-LC p>0.05; non-LC VS Child's class C p<0.023). Ascites leakage or wound infection were not observed. CONCLUSION: Inguinal hernioplasty can be safely performed for LC patients in Child's class A and B; for patients in class C, careful attention must be paid to the hemorrhagic events. KEY WORDS: Ascites, Cirrhosis, Hernioplasty.

Necrotizing Soft Tissue Fasciitis after Intramuscular Injection.

Necrotizing soft tissue fasciitis (NSTIs) or necrotizing fasciitis is an infrequent and serious infection. Herein, we describe the clinical course of a female patient who received a diagnosis of NSTIs after gluteus intramuscular injection. We also report the results of our review of published papers from 1997 to 2017. Since now, 19 cases of NSTIs following intramuscular injections have been described. We focus on the correlation between intramuscular injection and NSTIs onset, especially in immunosuppressed patients treated with corticosteroids, suffering from chronic diseases or drug addicted. Intramuscular injections can provoke severe tissue trauma, representing local portal of infection, even if correctly administrated. Otherwise, it is important not to inject drug in subcutaneous, which is a less vascularized area and therefore more susceptible to infections. Likewise, a proper injecting technique and aspiration prior to injection seem to be valid measure to prevent intra-arterial or para-arterial drug injection with the consequent massive inflammatory reaction. Necrosis at the infection site appears to be independent of the drug, and it is a strong additional risk factor for NSTIs.

Acute inflammatory response in the subcutaneous versus periprosthethic space after incisional hernia repair: an original article.

BACKGROUND: The acute inflammatory response following mesh implantation has been often evaluated in vitro and in animal models. The aim of this study was to evaluate the acute inflammatory response near the prosthesis in human by analysing some inflammatory indicators. METHODS: We used a cohort of twelve male patients affected by midline incisional hernia, who were admitted for surgical mesh repair. A suction drain was placed between the mesh and rectal muscles whereas, the other one was placed between the subcutaneous tissue and the oblique external sheath. The acute inflammatory response was analyzed by measuring the production of interleukin [IL]-1, IL-10, IL-1ra, C-Reactive Protein (CRP), total proteins, albumin and pH in the drain fluids. RESULTS: The dynamics of CRP and ILs production resulted similar in both drainages. Comparing drain over mesh and subcutaneous drain at all times, IL-1 and CRP values always resulted significantly higher in the first one, whereas IL-1ra and IL-10 values were significantly higher in the last one. Total protein and albumin were similar in both drains at all time; only in the drain over mesh fluid, pH values resulted significantly reduced in the fourth post-operative day. CONCLUSIONS: Our data showed that an acute inflammatory reaction is present in both sites examined. However, it was significantly higher in the space after mesh implantation.

Concomitant small cell neuroendocrine carcinoma of gallbladder and breast cancer.

The neuroendocrine carcinoma is defined as a high-grade malignant neuroendocrine neoplasm arising from enterochromaffin cells, usually disposed in the mucosa of gastric and respiratory tracts. The localization in the gallbladder is rare. Knowledge of these gallbladder tumors is limited and based on isolated case reports. We describe a case of an incidental finding of small cell neuroendocrine carcinoma of the gallbladder, observed after cholecystectomy for cholelithiasis, in a 55-year-old female, who already underwent quadrantectomy and sentinel lymph-node biopsy for breast cancer. The patient underwent radiotherapy for breast cancer and six cycles of chemotherapy with cisplatin and etoposide. Eighteen months after surgery, the patient was free from disease. Small cell neuroendocrine carcinoma of the gallbladder has poor prognosis. Because of the rarity of the reported cases, specific prognostic factors have not been identified. The coexistence of small cell neuroendocrine carcinoma of the gallbladder with another malignancy has been reported only once. The contemporary presence of the two neoplasms could reflect that bioactive agents secreted by carcinoid can promote phenotypic changes in susceptible cells and induce neoplastic transformation.

Giant retroperitoneal leiomyoma: a case report and review of the literature.

UNLABELLED: Retroperitoneal leiomyomata are infrequent, and their prevalence among primary retroperitoneal tumours has been estimated as 0.5-1.2%. The authors report a case of symptomatic retroperitoneal leiomyoma with a favourable prognosis. A 53-year-old woman presented for abdominal pain associated to an inflammatory syndrome. A contrast-enhanced computed tomography revealed a large abdominopelvic mass and patient underwent open surgical excision. Definitive diagnosis was done after immunohistochemical assessment. Immunoreactivity was strong for smooth muscular actin. Presence of oestrogen and progesterone receptor proteins was also detected. Prognosis of these well-differentiated smooth muscle tumours is generally favourable but a postoperative surveillance is always recommended. KEY WORDS: Leiomyoma, Retroperitoneal space, Surgery.

Short-stay hospitalisation for benign thyroid surgery: a prospective study.

We report our prospective experience of short-stay hospitalisation for benign thyroid surgery. Post-operative outcome, complication rate and duration of hospitalisation were evaluated for 200 similar patients with bilateral multi-nodular goitres treated surgically by total thyroidectomy. All subjects gave written informed consent. A short-stay regimen, with discharge within 24 h of admission, was possible in 92.5 %. Fourteen (7 %) were discharged on the second post-operative day and one on the fourth post-operative day. Causes of the 15 delayed discharges beyond 24 h were 11 hypocalcaemia (5.5 %), 3 haematoma (1.5 %) and 1 dysphonia (0.5 %). All compressive haematoma were treated by urgent reoperation. No mortality occurred. None required tracheostomies. Transient complications were diagnosed in 36 cases: 25 with hypocalcaemia and 11 with recurrent laryngeal nerve injuries. Permanent complications were observed in three patients: two with hypoparathyroidism and one with nerve damage. All patients were carefully counselled about potential thyroid surgery complications and a 24-h emergency-contact number was provided. Short-stay hospitalisation represents safe and cost-saving surgical management for benign thyroid surgery.

Intestinal melanoma: A broad spectrum of clinical presentation.

INTRODUCTION: Small intestine melanomas are rare and the most of them are metastases from primary cutaneous neoplasms. PRESENTATION OF CASE: Below, we report two cases of small intestine metastatic melanoma with very different clinical presentation. DISCUSSION: Still now, primary versus metastatic origin is often unclear. Small bowel melanoma is often asymptomatic. However, clinical picture can be various; it may occurs with non specific symptoms and signs of gastro-intetstinal involvement, like chronic abdominal pain, occult or gross bleeding and weight loss, or with an emergency picture due to intestinal intussusception, obstruction or, rarely, perforation. CONCLUSION: Small bowel melanoma is rare and the diagnosis done late. Imaging techniques are recommended in order to obtain early diagnosis of gastrointestinal metastases.

Manometric evaluation of internal anal sphincter after fissurectomy and anoplasty for chronic anal fissure: a prospective study.

Chronic anal fissure (CAF) is a common painful clinical disease and its pathogenesis remains poorly understood. After failure of pharmacological therapy, that is the first-line treatment, surgical sphincterotomy remains the treatment of choice although it is followed by a high rate of anal incontinence resulting from the sphincter damage; therefore, the research of a sphincter-saving surgical option has become an important goal. The aim of this study was to evaluate the manometric modifications and the incidence of anal incontinence after fissurectomy and anoplasty with advancement skin flap in patients affected by CAF with hypertonia of the internal anal sphincter (IAS). Fifteen patients affected by CAF with hypertonia of IAS, unresponsive to medical therapy, were enrolled. All subjects underwent fissurectomy and anoplasty with advancement skin flap. Anorectal manometry was performed preoperatively and after 6 and 12 months from surgery. Maximum resting pressure (MRP), maximum squeeze pressure (MSP), ultraslow wave activity (USWA), fissure healing, anal continence, and postoperative complications were recorded. All patients healed within 30 days from surgery. No intra- or postoperative complications were recorded except for a case of partial donor site break. No significant modifications of MSP were detected. Six months after surgery, MRP was higher with respect to healthy subjects but significantly reduced in comparison to baseline levels. At 12 months, it was higher have versus 6-month values but significantly lower versus preoperative values. USWA was significantly represented in patients with CAF versus healthy subject. Both at 6 and 12 months, they decreased significantly with respect to preoperative values without significant differences versus healthy subjects. Both at 6 and 12 months, anal continence did not differ with respect to preoperative time. The fissurectomy with anoplasty resulted in a high healing rate without surgical sequelae or anal incontinence. Also, it was able to reduce IAS pressure in the same manner as surgical sphincterotomy or forceful dilatation.

Advancement flap in the management of chronic anal fissure: a prospective study.

Lateral internal sphincterotomy is the surgical treatment of choice of chronic anal fissure after failure of conservative measures. Several randomized trials identified an overall risk of incontinence of 10 % mostly for flatus. Fissurectomy is the most commonly used procedure to preserve the integrity of the anal sphincters. However, a possible complication is keyhole defect that may lead to faecal soiling. In this study, chronic anal fissure (CAF) was treated by fissurectomy and anal advancement flap to preserve the anatomo-functional integrity of sphincters and to reduce healing time and the risk of anal stenosis. In patients with hypertonia, surgical treatment was combined with chemical sphincterotomy by injection of botulinum toxin to enhance tissue perfusion. Forty eight patients with CAF underwent fissurectomy and anal advancement flap. In 22 subjects with hypertonia of the internal anal sphincter, intrasphincter injection of 30 UI of botulinum toxin at the completion of the surgical operation was used. All patients were followed up to 24 months. Since the first defecation, the intensity and duration of pain were significantly reduced. Two patients had urinary retention, five had infections and three had partial breakdowns. No anal stenosis, keyhole deformity or necrosis flap was recorded. At the 24 months follow-up visit, anal incontinence was similar to those detected preoperatively. Only four recurrences were detected at 18 and 20 months. After medical treatment failure, fissurectomy with advancement flap is a valid sphincter-conserving procedure for treatment of anterior or posterior CAF, regardless of hypertonia of the internal anal sphincter.

Risk factors for postoperative delirium after colorectal surgery for carcinoma.

BACKGROUND AND AIM: Data regarding the incidence and risk factors for postoperative delirium (PD) after gastrointestinal surgery are heterogeneous because they include both benign and malignant disease. The aim of this study was to investigate the incidence and risk factors for PD in 100 consecutive patients over 65 years who underwent colorectal surgery for carcinoma. METHODS: Pre-operative cognitive function was assessed using the Mini Mental State Examination. The onset of PD was diagnosed by the Confusion Assessment Methods administered to the patients every 12 h starting from the first postoperative day to discharge. The severity of PD was also evaluated with the Delirium Rating Scale. Different parameters: pre-, intra- and postoperative, were analyzed. Univariate and multivariate analyses were performed. RESULTS: PD developed in 18% of patients. Univariate analysis revealed that advanced age, a history of PD, alcohol abuse, lower blood albumin concentration, intra-operative hypotension, elevated infusion volume and excessive blood loss were significantly related to the development of PD. On multivariate analysis, only lower levels of albumin, alcohol abuse, and hypotension were independent risk factors for PD. CONCLUSIONS: These findings suggest that PD is a frequent complication after colorectal surgery for carcinoma. A model based on pre, intra and postoperative risk factors allows prediction of the patient's risk for developing PD in order to implement preventive measures for this complication.

Impact of heavy polypropylene mesh and composite light polypropylene and polyglactin 910 on the inflammatory response.

The aim of the study was to analyze the acute inflammatory response after implantation of a heavyweight mesh of polypropylene (PP) compared with a composite mesh of light PP and polyglactin 910 (PG) in patients undergoing inguinal hernioplasty. A total of 30 male patients with inguinal hernia were included in the study and divided into 2 groups (PP and PP-PG) according to the mesh used. Changes of leukocytes, cytokines, growth factors, and acute phase proteins were evaluated in the sera. Leukocytes and acute phase proteins were significantly increased postoperatively in both groups, and the values were slightly higher in the PP group. Cytokine levels were significantly increased postoperatively in both groups; a slight increase was observed in the PP-PG group, especially for the proinflammatory cytokine. Growth factors decreased significantly in both groups immediately after surgery. The authors found that the use of the mesh is a stimulator of inflammatory response, and the 2 types of mesh induce a similar inflammatory response.

Changes of inflammatory mediators in obese patients after laparoscopic cholecystectomy.

BACKGROUND: Obesity is associated with the impairment of immunological functions. The aim of this study was to analyze some inflammatory mediators in obese subjects who underwent laparoscopic cholecystectomy. METHODS: Seventeen consecutive female patients with a BMI ranging from 35 to 45 kg/m(2) (obese) and 17 consecutive female patients with BMI ranging from 20 to 25 kg/m(2) (nonobese) were included in the study. All patients were affected by symptomatic gallbladder stone disease and underwent laparoscopic cholecystectomy. Changes in levels of leukocytes, neutrophils, IL-6, IL-10, leptin, and adiponectin were evaluated. RESULTS: We observed a significant increase in leukocyte and neutrophil levels in the obese subjects compared to the nonobese subjects. The serum levels of leptin and IL-6 were higher in the postoperative period (compared to the baseline values in both groups), and always higher in the obese. Both adiponectin and IL-10 increased in the postoperative period in nonobese subjects and was always higher than in the obese. CONCLUSIONS: Obese patients have a stronger acute inflammatory response than do nonobese subjects in reaction to surgical stress.

Splenic lymphangiomatosis showing rapid growth during lactation: a case report.

Splenic lymphangiomatosis is a very rare condition that, from 1990 to date, has been described only nine times. In the present report, we describe the first case of splenic lymphangiomatosis with rapid growth during lactation in a 35-year-old woman. We also underline the difficultly in making an accurate preoperative diagnosis, despite more modern imaging techniques. Total splenectomy was considered to be the treatment needed, both to make a definitive diagnosis and to exclude the presence of malignancy.

Early results of fissurectomy and advancement flap for resistant chronic anal fissure without hypertonia of the internal anal sphincter.

The aim of this study was to assess the efficacy of fissurectomy with skin advancement flap in healing chronic anal fissures without hypertonia of the internal anal sphincter. Twenty-six consecutive patients who failed healing after well-practiced topical medical therapy were enrolled. Anorectal manometry was performed preoperative and 6 months postoperatively. All patients were treated with fissurectomy and advancement flap through healthy skin tissue. All patients healed completely within 30 days from operation. The intensity and the duration of pain post-defecation was reduced significantly with respect to the preoperative values starting from the first defecation. One patient suffered urinary retention, two patients suffered infections, and two partial breakdowns were recorded. At 6 months the maximum resting pressure values were similar to those were detected preoperatively. One month after surgery, anal incontinence was reported in seven patients, four of whom complained about it preoperatively. At 12 months, only three subjects reported incontinence. No patients needed reoperation and no recurrences were detected. The fissurectomy, in combination with advancement flap, is a safe sphincter-saving procedure for the treatment of chronic anal fissures without hypertonia of internal anal sphincter that fails medical conservative treatment.