Endoscopic Treatment of Iatrogenic Perforation of Sigmoid Diverticulum: A Case Report of Multidisciplinary Management.

Iatrogenic perforations are severe complications of gastrointestinal endoscopy; therefore, their management should be adequately planned. A 77-year-old man with a history of diverticulosis underwent a colonoscopy for anemia. During the procedure, an iatrogenic perforation occurred suddenly in the sigmoid colon, near a severe angle among the numerous diverticula. Through-the-scope clips were immediately applied to treat it and close mucosal edges. Laboratory tests showed increased levels of inflammation and infection, and although there were no complaints of abdominal pain, the patient had an extremely distended abdomen. A multidisciplinary board began management based on a conservative approach. Pneumoperitoneum was treated with computed tomography-assisted drainage. After 72 hours, his intestinal canalization and laboratory tests were normal. Though this adverse event is rare, a multidisciplinary board should be promptly gathered upon occurrence, even if the patient appears clinically stable, to consider a conservative approach and avoid surgical treatment.

Fissurectomy and anoplasty in posterior normotensive chronic anal fissure.

PURPOSE: Anal Fissure (AF) is the second most frequent proctological disease in Italy. Chronic AF (CAF) most common located at the posterior anal commissure (CAPF). CAPF are thought to be associated with hypertonic internal anal sphincter (IAS) but manometric findings showed that a normotonic IAS is present in the 20-40%. Sphincterotomy is often recommended as treatment of choice for CAF independently from IAS tone; nevertheless, this approach appears less logical for CAF with normotonic IAS, as in those cases there's a higher risk of post-operative anal incontinence. The aim of this study is to evaluate the results of fissurectomy and anoplasty with V-Y cutaneous advancement flap, as treatment for patients suffering from CAPF without hypertonic IAS. METHODS: We enrolled 30 patients affected by CAPF without IAS hypertonia. All patients were followed up for 2 years after the surgical procedure, with evaluation of anal continence, recurrence rate and maximum resting pressure, maximum squeeze pressure, ultraslow wave activity. RESULTS: All patients healed within 40 days after surgery. We didn't observe any "de novo" post-operative anal incontinence cases. We reported 2 cases of recurrences, within 18 months from surgery, all healed after conservative therapy. We didn't record statistically significant differences in pre- and post-operative manometry findings. CONCLUSION: At 2 years after the surgical procedure we achieved good results, these evidences shows that sphincter preserving procedures are more suitable for CAPF without hypertonic IAS.

Mirizzi syndrome type V complicated with both cholecystobiliary and cholecystocolic fistula: a case report.

Mirizzi syndrome (MS) is a common bile duct (CBD) obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Patients affected by MS may present abdominal pain and jaundice. A 37-year-old male with neurologic residuals post-encephalitis arrived at the emergency department reporting abdominal pain, jaundice and fever. An ultrasound of the abdomen identified cholecystolithiasis with a dilated CBD. He did not undergo CT or MRI due to poor compliance and parents' disagreement. Eventually, they accepted to perform endoscopic retrograde cholangiopancreatography, which diagnosed MS with both cholecystobiliary and cholecystocolonic fistula without gallstone ileum (type Va). Therefore, patient underwent cholecystectomy, wedge resection of the colon and choledochoplasty with 'Kehr's T-tube' insertion. A plastic biliary stent was successively placed and removed after 4 month. Ultimately, he did neither complain any other biliary symptoms nor alteration in laboratory tests after 4-years of follow-up.

Lateral Internal sphincterotomy is still crucial to heal hypertonic chronic anal fissure and normalize the internal anal sphincter tone? Is V-en Y plastic a valuable alternative?

INTRODUCTION: The role of augmented internal anal sphincter (IAS) tone in the genesis of chronic anal fissure (CAF) is still unclear. Lateral internal sphincterotomy (LIS) is the most employed surgical procedure, aiming to reduce the IAS tone leaving a permanent anatomical alteration and it is burdened by high risk post-operative anal incontinence (AI). The aim of this work was to evaluate if the pre-operative manometric alterations of CAFs with hypertonic IAS would normalize after sphincter preserving surgical procedure. METHODS: We enrolled 108 consecutive patients affected by idiopathic and non-recurrent CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement and pharmacological sphincterotomy, matched with 54 healthy subject in a 1 to 2 ratio, and followed up for at least for 2 years. The goals were patient's complete healing, the evaluation of AI, recurrence rate and manometry parameters. RESULTS: All wounds healed within 40 days after surgery. We recorded 7 cases of recurrences healed with medical therapy. We recorded 3 "de novo" post-operative cases of AI all temporary and low grade. Pre-operative values of maximum resting pressure (MRP) and detection of ultraslow wave activity (USWA) were significantly higher than in the healthy control group, but both come back to be similar to those recorded in healthy subject after 24 months from the surgery. CONCLUSION: The high healing rate without post-operative "de novo" AI cases with the normalization of manometric parameters suggest that fissurectomy and anoplasty with V-Y cutaneous advancement flap and pharmacological sphincterotomy is an adequate procedure for the treatment of CAF with IAS hypertonia. KEY WORDS: Anal fissure, Anoplasty, Fissurectomy, Proctology, Sphincterotomy.

Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation.

Chronic anal fissure's (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V-Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V-Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 "de novo" post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up post-operative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF.

Effect of Fibrin Sealant on Seroma Formation Post-Incisional Hernia Repair.

Background: Development of seroma after incisional hernia repair is a common complication. Our study aims to compare the outcomes of sublay incisional hernia repairs with or without spray instillation of fibrin glue. Methods: We enrolled fifty patients undergoing incisional hernia repair. In all patients a suction drain was placed in the subcutaneous space. In one group (FG) 4 ml fibrin glue was instilled in the subcutaneous space. In the control group (C) patients did not receive any prevention measure. Wounds fluids were collected on post-operative day 1 (POD) and once daily until drain removal. All patients were followed up by ultrasound on POD 15, 20, 40, 60. Results: Drain fluid production, even if in significantly greater amount in the C group (p 0.01) as compared with the FG group, decreased after POD 1 in both groups. Drain was removed on POD-5 in 80% of FG patients and in 36% of C patients (p 0.01). No infective or bleeding complications were detected. In group FG average hospital stay was of 5.5 ÃÂ+- 2 days versus 7.1 +- 1.5 days in group C (p 0.01). At ultrasounds examination, seroma development was similar among two groups. Conclusions: Spray instillation of fibrin glue during the surgical repair reduces amount of drained fluid and hospital stay without increasing surgical complications. However, seroma occurrence was not significantly reduced.

Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter.

PURPOSE: The role of augmented internal anal sphincter (IAS) tone in the genesis of posterior chronic anal fissure (CAPF) is still unknown. Lateral internal sphincterotomy is the most employed surgical procedure, nevertheless it is burdened by high risk post-operative anal incontinence. The aim of our study is to evaluate results of sphincter saving procedure with post-operative pharmacological sphincterotomy for patients affected by CAPF with IAS hypertonia. Methods: We enrolled 30 patients, undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement; all patients received topical administration of nifedipine 0.3% and lidocaine 1.5% ointment-based therapy before and for 15 days after surgery. The primary goal was patient's complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of manometry parameters, symptom relief and complications related to nifedipine and lidocaine administration. Results: All wounds healed within 40 days after surgery. We didn't observe any de novo postoperative anal incontinence case. We reported 2 cases of recurrences, healed after conservative therapy. We didn't report any local complications related to the administration of the ointment therapy; with whom all patients reported a good compliance. Conclusions: Fissurectomy and anoplasty with V-Y cutaneous advancement flap and topical administration of nifedipine and lidocaine, is an effective treatment for CAPF with IAS hypertonia.

Long term outcomes of fissurectomy and anoplasty for chronic anterior anal fissure without hypertonia: low recurrences and continence conservation.

INTRODUCTION: Aetiopathogenesis of Chronic Anal Anterior Fissure (CAAF) remains poorly understood. Some anatomical, clinical and functional features suggest that pathophysiology may be linked to a reduced anal canal pressure. LIS appear illogical as a treatment for CAAF and the employ of techniques aiming to save the integrity of the sphincterial system appears more sensible. The aim of this study was to evaluate 5 years results of fissurectomy and anoplasty with cutaneous V-Y advancement flap in patients affected by CAAF without IAS hypertonia. METHODS: We enrolled 20 women, affected by idiopathic and non-recurrent CAAF without hypertonic IAS. All patients were followed up for 5 years after surgery with evaluation of anal continence, short and long term post-operative complications, recurrence rate. RESULTS: At 5 years follow up we did not record any new case of anal incontinence and the pre-existing ones haven't worsened. We observed 2 recurrences, which occurred within 2 years after surgery and healed after medical therapy. The manometric values were similar than those recorded prior to surgery. CONCLUSION: Our study suggests that the procedure performed allows us to preserve anal continence and avoid worsening of its pre-existing alteration. KEY WORDS: Anal canal, Anoplasty, Fissure, Fissurectomy, Proctology, Sphincterotomy.

Mirizzi syndrome in a patient with partial gastrectomy with Billroth II anastomosis: A case report.

INTRODUCTION: Mirizzi Syndrome (MS) is a common bile duct (CBD) obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Radiological evaluation may mistake it for CBD stones in jaundiced patient, especially in those who have altered anatomy of upper gastrointestinal (e.g. sub-total gastrectomy - STG - with Billroth I or II anastomosis). PRESENTATION OF CASE: A 69-year-old male with a history of STG Billroth-II 25 years prior, accessed hospital for abdominal pain and jaundice with increasing in hepatic laboratory tests. Ultrasound of abdomen, CT scan and MRCP diagnosed CBD stones, so endoscopic retrograde cholangiopancreatography (ERCP) was performed, using a gastroscope to reach papillary region and to achieve cannulation of biliary duct. During cholangiography patient resulted affected by Mirizzi syndrome type I, so laparoscopic cholecystectomy was performed and cystic duct was moved away. DISCUSSION: This rare case shows how it's easy to delay the correct treatment when a wrong radiological diagnosis is made. Moreover, ERCP remains a challenging procedure in patients with altered anatomy, such as STG B-II, and in this case gastroscope was needed for cannulation, due to the need of frontal view. CONCLUSION: This rare case report highlights the importance of not forgetting MS in the differential diagnosis of biliary obstruction, especially in those patients with upper GI altered anatomy. Physicians with expertise in ERCP should always consider altered anatomy as a factor which may confuse radiologist in diagnosis, so in this case MS may be discovered or confirmed at ERCP.

Ileal Melanoma, A Rare Cause of Small Bowel Obstruction: Report of a Case, and Short Literature Review.

BACKGROUND: Malignant melanoma frequently spreads to the gastrointestinal tract, with 60% of patients with advanced metastatic disease showing digestive involvement; however, primary MM of the small intestine is a controversial diagnosis. In fact, whether these lesions arise as true small bowel primary neoplasms or represent metastases from unidentified cutaneous melanomas remains debatable. The most common complications are intestinal obstruction, massive gastrointestinal bleeding, and perforation. OBJECTIVE & METHODS: We report a case of a 64-year-old patient, with an unremarkable medical history, in which a late diagnosis of primary ileal malignant melanoma in the setting of an emergency laparotomy due to small bowel obstruction, and where PET-scan showed costal metastasis. Therefore, we provide a narrative review of the scientific literature about this topic. RESULTS: 36 cases of primary small bowel melanoma, included that in the present study, were found through our search in the scientific literature. CONCLUSION: Primary small bowel MM appears to be an extremely rare entity which clinicians should be more aware of, in order to plan better a correct strategy of early diagnosis and appropriate treatment.

Endoscopic papillary large balloon dilation in patients with large biliary stones and periampullary diverticula: Results of a multicentric series.

INTRODUCTION: Stone extraction represents the most frequent indication for endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic papillary large balloon dilation (EPLBD) is a recent introduced approach consisting of an endoscopic papillary large balloon dilation following limited endoscopic sphyncterotomy (ES), which has been proven to be safe and effective for extraction of large common bile duct (CBD) stones. Peri-ampullary diverticula (PAD) are described in 10-20% of patients undergoing ERCP. Aim of our study is to evaluate efficacy and safety of EPLBD for the extraction of large biliary stones in patients with PAD. METHODS: The prospectively collected endoscopy databases of 4 Italian ERCP high-volume centers were reviewed retrospectively, and all consecutive patients with an instrumental diagnosis of large biliary stones and PAD, between September 2014 and October 2016, were included in this study. RESULTS: Eighty-one patients (36 males, median age 75 years) were treated between September 2014 and October 2016. Deep biliary cannulation was reached in 78/80 patients. Successful extraction was achieved in 74/78 patients at the first attempt. AEs occurred in 8 patients (1 severe). Younger age, stone size and incomplete stone extraction were significantly associated with AEs. CONCLUSIONS: EPLBD is an effective and safe technique in patients with PAD and large biliary stones, which avoids the need of other techniques, thereby reducing the risks of adverse events.

Retrospective analysis of management of ingested foreign bodies and food impactions in emergency endoscopic setting in adults.

BACKGROUND: Ingestion of foreign bodies and food impaction represent the second most common endoscopic emergency after bleeding. The aim of this paper is to report the management and the outcomes in 67 patients admitted for suspected ingestion of foreign body between December 2012 and December 2014. METHODS: This retrospective study was conducted at Palermo University Hospitals, Italy, over a 2-year period. We reviewed patients' database (age, sex, type of foreign body and its anatomical location, treatments, and outcomes as complications, success rates, and mortalities). RESULTS: Foreign bodies were found in all of our 67 patients. Almost all were found in the stomach and lower esophagus (77 %). The types of foreign body were very different, but they were chiefly meat boluses, fishbones or cartilages, button battery and dental prostheses. In all patients it was possible to endoscopically remove the foreign body. Complications related to the endoscopic procedure were unfrequent (about 7 %) and have been treated conservatively. 5.9 % of patients had previous esophageal or laryngeal surgery, and 8.9 % had an underlying esophageal disease, such as a narrowing, dismotility or achalasia. CONCLUSION: Our experience with foreign bodies and food impaction emphasizes the importance of endoscopic approach and removal, simple and secure when performed by experienced hands and under conscious sedation in most cases. High success rates, lower incidence of minor complications, reduction of the need of surgery and reduced hospitalization time are the strengths of the endoscopic approach.

Heat shock protein 60 levels in tissue and circulating exosomes in human large bowel cancer before and after ablative surgery.

BACKGROUND: Heat shock protein 60 (Hsp60) is a chaperonin involved in tumorigenesis, but its participation in tumor development and progression is not well understood and its value as a tumor biomarker has not been fully elucidated. In the current study, the authors presented evidence supporting the theory that Hsp60 has potential as a biomarker as well as a therapeutic target in patients with large bowel cancer. METHODS: The authors studied a population of 97 subjects, including patients and controls. Immunomorphology, Western blot analysis, and quantitative real-time polymerase chain reaction were performed on tissue specimens. Exosomes were isolated from blood and characterized by electron microscopy, biochemical tests, and Western blot analysis. RESULTS: Hsp60 was found to be increased in cancerous tissue, in which it was localized in the tumor cell plasma membrane, and in the interstitium associated with cells of the immune system, in which it was associated with exosomes liberated by tumor cells and, as such, circulated in the blood. An interesting finding was that these parameters returned to normal shortly after tumor removal. CONCLUSIONS: The data from the current study suggested that Hsp60 is a good candidate for theranostics applied to patients with large bowel carcinoma and encourage similar research among patients with other tumors in which Hsp60 has been implicated.

High Proportions of People With Nonceliac Wheat Sensitivity Have Autoimmune Disease or Antinuclear Antibodies.

BACKGROUND & AIMS: There is much interest in wheat sensitivity among people without celiac disease (CD), but little is known about any risks associated with the condition. We evaluated the prevalence of autoimmune diseases (ADs) among patients with nonceliac wheat sensitivity (NCWS), and investigated whether they carry antinuclear antibodies (ANA). METHODS: We performed a retrospective study of 131 patients diagnosed with NCWS (121 female; mean age, 29.1 years) at 2 hospitals in Italy from January 2001 through June 2011. Data were also collected from 151 patients with CD or irritable bowel syndrome (IBS) (controls). Patient medical records were reviewed to identify those with ADs. We also performed a prospective study of 42 patients (38 female; mean age, 34 years) diagnosed with NCWS from July 2011 through March 2014 at 3 hospitals in Italy. One hundred age- and sex-matched subjects with CD or IBS served as controls. Serum samples were collected from all subjects and ANA levels were measured by immunofluorescence analysis. Participants completed a questionnaire and their medical records were reviewed to identify those with ADs. RESULTS: In the retrospective analysis, similar portions of subjects with NCWS (29%) and CD (29%) developed ADs (mainly Hashimoto's thyroiditis, 29 cases), compared with a smaller proportion of subjects with IBS (4%) (P < .001). In the prospective study, 24% of subjects with NCWS, 20% of subjects with CD, and 2% of subjects with IBS developed ADs (P < .001). In the retrospective study, serum samples tested positive for ANA in 46% of subjects with NCWS (median titer, 1:80), 24% of subjects with CD (P < .001), and 2% of subjects IBS (P < .001); in the prospective study, serum samples were positive for ANA in 28% of subjects with NCWS, 7.5% of subjects with CD (P = .02), and 6% of subjects with IBS (P = .005 vs patients with NCWS). ANA positivity was associated with the presence of the HLA DQ2/DQ8 haplotypes (P < .001). CONCLUSIONS: Higher proportions of patients with NCWS or CD develop autoimmune disorders, are ANA positive, and showed DQ2/DQ8 haplotypes compared with patients with IBS.

A case of splenic rupture: a rare event after laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is generally safe and well-accepted. In rare cases, it is associated with complications (intra- e postoperative bleeding, visceral injury and surgical site infection). Splenic lesion has been reported only after direct trauma. We report an unusual case of splenic rupture presenting after "uncomplicated" LC. CASE PRESENTATION: A 77-year-old woman presented with distended abdomen, tenderness in the left upper quadrant and severe anemia 12 hours after LC. Clinical examination revealed hypovolemic shock. Abdominal computed tomography confirmed the diagnosis of splenic rupture, and the patient required an urgent splenectomy through midline incision. The post-operative course was uneventful and the patient was discharged on 7th postoperative day.Splenic injury rarely complicates LC. We postulate that congenital or post-traumatic adhesions of the parietal peritoneum to the spleen may have been stretched from the splenic capsule during pneumoperitoneum establishment, resulting in subcapsular hematoma and subsequent delayed rupture. CONCLUSIONS: Splenic rupture is an unusual but life-threatening complication of LC. Direct visualization of the spleen at the end of LC might be a useful procedure to aid early recognition and management in such cases.

Risk of low bone mineral density and low body mass index in patients with non-celiac wheat-sensitivity: a prospective observation study.

BACKGROUND: Non-celiac gluten sensitivity (NCGS) or 'wheat sensitivity' (NCWS) is included in the spectrum of gluten-related disorders. No data are available on the prevalence of low bone mass density (BMD) in NCWS. Our study aims to evaluate the prevalence of low BMD in NCWS patients and search for correlations with other clinical characteristics. METHODS: This prospective observation study included 75 NCWS patients (63 women; median age 36 years) with irritable bowel syndrome (IBS)-like symptoms, 65 IBS and 50 celiac controls. Patients were recruited at two Internal Medicine Departments. Elimination diet and double-blind placebo controlled (DBPC) wheat challenge proved the NCWS diagnosis. All subjects underwent BMD assessment by Dual Energy X-Ray Absorptiometry (DXA), duodenal histology, HLA DQ typing, body mass index (BMI) evaluation and assessment for daily calcium intake. RESULTS: DBPC cow's milk proteins challenge showed that 30 of the 75 NCWS patients suffered from multiple food sensitivity. Osteopenia and osteoporosis frequency increased from IBS to NCWS and to celiac disease (CD) (P <0.0001). Thirty-five NCWS patients (46.6%) showed osteopenia or osteoporosis. Low BMD was related to low BMI and multiple food sensitivity. Values of daily dietary calcium intake in NCWS patients were significantly lower than in IBS controls. CONCLUSIONS: An elevated frequency of bone mass loss in NCWS patients was found; this was related to low BMI and was more frequent in patients with NCWS associated with other food sensitivity. A low daily intake of dietary calcium was observed in patients with NCWS.

Comparative analysis of Hsp10 and Hsp90 expression in healthy mucosa and adenocarcinoma of the large bowel.

BACKGROUND: Heat shock proteins (Hsps) assist other proteins in their folding and drive the degradation of defective proteins. During evolution, these proteins have also acquired other roles. Hsp10 is involved in immunomodulation and tumor progression. Hsp90 stabilizes a range of "client" proteins involved in cell signaling. The present study evaluated the expression levels of Hsp10 and Hsp90 in normal mucosa and adenocarcinoma samples of human large bowel. MATERIALS AND METHODS: Samples of normal mucosa and adenocarcinoma were collected and Reverse transcriptase-polymerase chain reaction RT-PCR, western blotting (WB) analyses, as well as immunohistochemistry were performed to evaluate the expression levels of Hsp10 and Hsp90. RESULTS: RT-PCR showed a higher gene expression of Hsp10 and Hsp90 in adenocarcinoma samples compared to healthy mucosa. WB results confirmed these findings. Immunohistochemistry revealed higher levels of Hsp10 in adenocarcinoma in both the epithelium and the lamina propria, while Hsp90 expression was higher in the adenocarcinoma samples only in the lamina propria. CONCLUSION: Hsp10 and Hsp90 may be involved in large bowel carcinogenesis.

Intradiverticular ampulla of vater: personal experience at ERCP.

Introduction. Conflicting results have been reported about the true impact of intradiverticula ampulla (IA) on the technical success and complication rate of endoscopic retrograde cholangiopancreatography (ERCP). Patients. A total of 500 patients who underwent ERCP were divided into two groups according to the presence (group A, 81 patients) or absence (group B, 419 patients) of IA. Success rate, difficulty at cannulation, findings at ERCP, and procedure-related complications were retrospectively reviewed. Results. Successful cannulation was achieved in 100% of group A patients compared to 98% of group B patients (P = ns). There was a significant difference in the type of cannulation that was routinary in group B (P < 0.05), while requiring guidewire in group A (P < 0.05). Cholangitis (P < 0.05), microstones (P < 0.01), dilated common bile duct without stones (P < 0.01), stone recurrence (P < 0.01), and transient postprocedure hyperamylasemia (P < 0.01) were more frequently observed in group A. There was no significant difference in complication rate between both groups. Conclusions. The finding of an IA at ERCP should not be considered a predictor for failed cannulation. IA is associated with post-ERCP transient hyperamylasemia and is a risk factor for biliary stone disease and its recurrence.