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.

NGF eye-drops topical administration in patients with retinitis pigmentosa, a pilot study.

BACKGROUND: Preclinical trials have shown beneficial effects of nerve growth factor (NGF) administration on visual function in animal models of retinitis pigmentosa (RP). The aim of this pilot study was to explore the potential efficacy of short term NGF eye drops treatment in patients affected by RP. METHODS: The trial consisted in 10 days daily administration of murine NGF as eye-drops for a total dose of 1 mg NGF/pt. Eight RP patients at an advanced stage of the disease were included in the trial. To monitor safety and potential adverse effects subjects underwent standard clinical measures and were requested to report any general or topic alterations following NGF assumption. Retinal function was assessed at baseline and after treatment by best-corrected visual acuity measurement (BCVA), macular focal electroretinogram (fERG) recording and Goldmann visual field testing. RESULTS: A transient tolerable local corneal irritation was the only adverse effect reported. fERG and BCVA remained within the limits determined by test-retest analysis of a large cohort of RP patients. Three patients reported a subjective feeling of improved visual performance. This was associated to a temporary enlargement of the visual field in all three patients and to improved fERG in two of the three. CONCLUSIONS: Short-term administration of NGF eye-drops caused neither significant adverse effects nor visual function losses in the tested RP patients. A minority of patients experienced an improvement of visual performance as shown by Goldmann visual field and fERG. This study supports the safety and possible efficacy of NGF eye-drops administration in RP patients. TRIAL REGISTRATION: EudraCT n. 2008-004561-26.

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.

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.

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.

Mesothelial cyst of the round ligament of the uterus A case report of a rare condition.

BACKGROUND: Differential diagnosis of inguinal mass must include, especially in female patients, a wide variety of lesions among which our analysis will focus on mesothelial cyst of the round ligament of the uterus. A rare developmental lesion often misdiagnosed as hernias and accidentally detected during surgical exploration of the groin region. CASE REPORT: Of a left inguinal mass causing local discomfort and progressive worsening of local pain. A pre-operative diagnosis of left symptomatic femoral hernia was made and the patient consented to surgical treatment. The surgical exploration of the inguinal and femoral canals revealed a femoral hernia associated to a clear fluid cystic lesion of around 2 cm arising from the round ligament. Histopathology demonstrated a mesothelial cyst of the round ligament CONCLUSIONS: Mesothelial cysts of the round ligament of the uterus must be taken into consideration in the differential diagnosis of groin swelling in female patients and a greater effort is needed in order to reach a preoperative diagnosis and prevent an over treatment. Key words: Mesothelial cyst, Preoperative diagnosis, Uterus.

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.

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.

Macular impairment in mitochondrial diseases: a potential biomarker of disease severity.

The high-energy demands of the retina are thought to contribute to its particular vulnerability to mitochondrial dysfunction. Photoreceptors are the cells with the higher oxygen consumption within the retina, and among these, the cones contain more mitochondria and have a higher energy demand than rods. A cohort of twenty-two patients with genetically-defined mitochondrial diseases (MDs) were enrolled to determine if the macula is functionally and anatomically impaired in these metabolic disorders. Visual acuity and fERG amplitude of patients with primary mitochondrial dysfunction were reduced compared to controls. Furthermore, SD-OCT layer segmentation showed a reduction of retinal and outer nuclear layer (ONL) volume in the macula of the patients. fERG amplitude showed a positive correlation with both ONL volume and thickness. A negative relationship was noted between fERG amplitude and disease severity assessed with Newcastle Mitochondrial Disease Adult Scale. In conclusion, MDs are associated with functional and anatomical alteration of macular cone system, characterized by its strong correlation with clinical disease severity suggesting a role as a potential biomarker of primary mitochondrial disorders.

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.

Superior mesenteric vein thrombosis following open right hemicolectomy and cholecystectomy. Casr report.

AIM: Superior mesenteric vein thrombosis (SMVT) is an uncommon but potentially life-threatening postoperative complication of colorectal surgery. Risk factors and prognosis of SMVT have been poorly described and data to create gold standard criteria for diagnosis and management are lacking. SMVT has a wide spectrum of clinical presentation, hence, its early identification may be a diagnostic challenge. CASE REPORT: 56 year old obese female patient with inherited prothrombotic condition underwent an open right hemicolectomy plus cholecystectomy; the immediate postoperative course was uneventful but on postoperative day 8, already at home, she experienced post-prandial abdominal pain without any other local or systemic signs or symptoms. The CT scan showed a complete thrombosis of the superior mesenteric vein without any bowel complications. Immediately submitted to systemic subcutaneous anticoagulation bridge therapy to a lifelong oral anticoagulation she had a complete clinical recovery on postoperative day 17, despite the persistence at CT scan of complete SMVT without any intestinal suffering. DISCUSSION: SMVT is a multifactorial event where both local and general factors are involved. Conclusive data about comparison of SMVT incidence in laparoscopic vs open colorectal surgery and those about its incidence in cancer vs non cancer groups of patients in relation to the surgical technique are missing. Variability of clinical course and the absence of specific signs, symptoms and laboratory findings make diagnosis of SMVT challenging, therefore it is crucial to have high suspicion. As for the treatment, first line approach is systemic anticoagulation therapy with LMWH for at least 6 months, followed by oral anticoagulation, the earlier we initiate the therapy the greater rate of recanalization we will get. CONCLUSION: prompt diagnosis and more aggressive thromboprophylaxis in patients with inherited or acquired risk factors may prevent the negative evolution towards bowel necrosis of SMVT. KEY WORDS: Colorectal surgery, Superior mesenteric vein thrombosis, Hypercoagulable disorders, Thromboprophylaxis.

Swept source optical coherence tomography and optical coherence tomography angiography in pediatric enhanced S-cone syndrome: a case report.

BACKGROUND: Enhanced S-cone syndrome is an autosomal recessive retinal dystrophy related to a defect in a nuclear receptor gene (NR2E3) that leads to alteration in cells development from rod to S-cone. This retinal dystrophy may be associated with retinal schisis. The aim of this report is to describe structural optical coherence tomography and optical coherence tomography angiography features in a case of enhanced S-cone syndrome associated with macular schisis. CASE PRESENTATION: A Caucasian 13-year-old girl underwent measurement of best corrected visual acuity, ophthalmoscopic evaluation, and fundus autofluorescence examination. Photopic and scotopic electroretinography were carried out as well. Enhanced S-cone syndrome was suspected on the basis of clinical and electrophysiological findings. Structural optical coherence tomography and optical coherence tomography angiography allowed the further characterization of the associated macular schisis. Genetic analysis not only confirmed the diagnosis but increased the clinical novelty of this case report by showing two variations in the NR2E3 gene probably related to the phenotype: a missense variation c.1118T>C which leads to the substitution of leucine with proline in amino acid position 373, and c.349+5G>C, which involves a gene sequence near a splicing site. CONCLUSIONS: Swept source structural optical coherence tomography (B scans and "en face" images) and optical coherence tomography angiography allowed the observation of retinal structural details and the involvement of each retinal layer and capillary plexus in enhanced S-cone syndrome. Of interest, neither of the two NR2E3 gene variants found in this case report have been linked to any form of retinopathy.

Neurotrophin family members as neuroprotectants in retinal degenerations.

BACKGROUND AND OBJECTIVES: Inherited retinal degenerations (IRDs) are an untreatable cause of blindness due to photoreceptor apoptosis. Blocking apoptosis by exogenous neurotrophic factor administration is a promising therapeutic strategy in IRDs. The neurotrophin (NT) family are a group of peptide growth factors homologous to nerve growth factor that regulate the development, differentiation, survival, and function of neuronal cells. This mini-review summarizes the preclinical evidence for neuroprotection of photoreceptors by NTs and explores the molecular pathways responsible for this protective effect. METHODS: Studies published in the literature over the past 20 years that report on the effect of NTs on apoptotic photoreceptor death in IRDs and light-induced retinal degeneration, and the cellular pathways involved, are reviewed. RESULTS: Preclinical evidence suggests that exogenous NT administration may be protective against photoreceptor apoptosis. Each NT exerts a neuroprotective effect on photoreceptors that is specific depending upon the model of retinal degeneration and the delivery system. Signaling pathways and retinal cells mediating this effect are still uncertain. Alternatively, different NTs may protect or damage photoreceptors depending on the expression pattern of high- and low-affinity NT receptors on the retinal cells. CONCLUSIONS: Although there is evidence that NTs may exert a protective effect, most likely indirectly on photoreceptor cell apoptotic degeneration in IRDs, the precise cellular and molecular mechanisms underlying this effect are still largely unknown. Better understanding of these mechanisms may greatly improve the rationale and efficacy of NT strategy for treatment of IRDs.