[Mesh infection in inguinal hernioplasty by Streptococcus dysgalactiae subspecies equisimilis. Case report and review of the literature]. / Infezione da Streptococcus dysgalactiae subspecies equisimilis in ernioplastica inguinale. Caso clinico e revisione della letteratura.

INTRODUCTION: Mesh infection in inguinal herniography is usually caused by Staphilococcus aureus and Staphilcoccus epidermidis. Generally it obliges to prosthesis removal with hernia relapse and increase of social costs for the prolongation of hospitalization. CASE REPORT: A 60-year-old woman, obese, undergone 4 months before to left inguinal prosthetic herniorrhaphy complicated by infection of the surgical site which didn't require the explantation of the mesh, although determining an early hernia relapse. She is submitted by the authors to a surgical intervention for left groin hernia relapse with placement of a polypropylene monofilament fixed with prolene. Six hours after the operation she shows systemic symptoms and local signs of prosthesis infection. Cultural examination of the surgical wound secretion allows the identification of Streptococcus dysgalactiae subspecies equisimilis (SDSE). A therapy with Amoxicillin-Clavulanic Acid and Levofloxacine leads to resolution, in 10 weeks, of the infection. DISCUSSION: In our case the infection of the new mesh, appearing prematurely, has been probably favoured by obesity and operative time longer than 3 hours. Conservative treatment has been fulfilled by success for the elevated sensitivity of the SDSE bacterium to penicillin and fluoroquinolones. CONCLUSIONS: Recent epidemiologic studies have demonstrated an increase of infections caused by SDSE, which will probably gain clinical relevance in the next future relatively to surgical prosthetic hernioplasty. In all cases of infection the authors suggest cultural isolation of the casual germ and the execution of the antibiogram because the conservative medical treatment can avoid mesh removal with consequent elevated risk of hernia relapse.

[A rare cause of acute abdomen: splenic infarction. Case report and review of the literature]. / Rara causa di addome acuto: l'infarto splenico. Caso clinico e revisione della letteratura.

INTRODUCTION: Splenic infarction is a rare cause of acute abdomen. It must be suspected in patient with hematologic diseases or thromboembolic conditions. The most common onset symptom is left-upper quadrant abdominal pain. Additional symptoms include fever and anemia. Laboratory may show elevated white blood cell and platelet counts. CASE REPORT: A 97-year-old female with a past history of atrial fibrillation presented with left-upper quadrant abdominal pain and fever since 20 days. Laboratory showed elevated white blood cell and platelet counts, increased C-reactive protein and lactate dehydrogenase. Both ultrasonographic and tomographic scans showed a large hypodense area of the spleen. The patient received intravenous antibiotic therapy, which led to significant clinical improvement with discharge 16 days after admission. DISCUSSION: The diagnosis of splenic infarction is based both on clinical presentation and imaging studies. Angio-computed tomography is the diagnostic procedure of choice. Ultrasonography and conventional radiology are useful in the differential diagnosis with other abdominal and thoracic diseases mimicking splenic infarction. In our case the management was conservative, because the patient was hemodynamically stable and antibiotic therapy could control the sepsis. Moreover, advanced age and poor cardiac and respiratory conditions contraindicated surgery. CONCLUSIONS: In our case splenic infarction was probably due to a thromboembolic event secondary to atrial fibrillation. In accordance with the literature, we suggest initial conservative therapy. Surgery is indicated only in the presence of complications.

Endoscopic sphincterotomy of the major duodenal papilla in acute relapsing pancreatitis associated with pancreas divisum: a case report.

We report a case of acute relapsing pancreatitis associated with pancreas divisum, who underwent major papilla sphincterotomy after failed minor papilla cannulation. Long-term results were satisfactory. The possible explanations of the efficacy of major papilla endoscopic resection in this particular case are discussed.

[Gallbladder polypoid lesions. Three clinical cases with difficult diagnosis and literature review]. / Lesioni polipoidi della colecisti. Presentazione di tre casi clinici di "difficile" diagnosi e revisione della letteratura.

INTRODUCTION: Gallbladder polypoid lesions occur in 1.3%-6.9% of cases. The preoperative diagnosis between benign, malignant and potentially malignant lesions is difficult. Therefore it is not possible any. PATIENTS AND METHODS: The Authors describe three cases. The case 1 was a gallbladder diffuse adenomyomatosis; the ultrasound and the CT were of little help in defining preoperatively the nature and the gravity of the thickening. Case 2 was an adenomyomatosis of the fundus: the ultrasound examinations were not able to establish preoperatively lesion's nature, site and dimensions. In the case 3, ultrasounds showed polypoid lesions and calculi concrections not found in colecistectomy. DISCUSSION: The ultrasound is the most widely used diagnostic tool in the evaluation of gallbladder polypoid lesions; its accuracy is only 66%. CT, which has an accuracy level of 75%, must be carried out there is any possibility of malignant degeneration of the polyp. If doubts persist, a MR, 93% accuracy, is indicated. In selected cases, PET can be of further help. CONCLUSIONS: The preoperative diagnosis of the nature of gallbladder polypoid lesions is "difficult" and this justifies the lack of consensus on treatment. However, the adenoma-carcinoma sequence, widely discussed in literature, can justifies to the use of CT, MR, PET and surgical treatment after an ultrasound examination.

[Unusual cause of acute abdomen in adult patient: gallstone ileus]. / Insolita causa di addome acuto in paziente adulto: l'ileo biliare.

INTRODUCTION: Gallstone ileus is a rare complication of cholecystolithiasis. It causes 1-3% of the mechanical obstructions of the small bowel. It often affects patients between 63 and 85 years old. Pre-operative diagnosis is usually delayed 1-10 days because there is not a specific symptomatology. CASE REPORT: The authors report the case of a 50 year-old man with diagnosis of mechanical obstruction of the small bowel caused by a voluminous gallstone. Ileal occlusion was showed by CT. The patient underwent to one-stage emergency surgery with enterolithotomy, cholecystectomy and duodenal fistula repair. Patient's recovery was regular and he was discharged fourteen days after surgery. DISCUSSION: In our case gallstone ileus was diagnosed with a delay of 5 days. Ultrasonography was not able to show the gallbladder. Diagnosis was made by CT, which is the diagnostic gold standard. CONCLUSION: Patient's performance status influences surgical strategy. In our experience, the patient underwent one-stage surgery because he was considered at low risk. Instead staged procedure with enterolithotomy and delayed cholecystectomy and fistula repair, is performed only in patients at high risk.

[Umbilical primary endometrioma. Case report]. / Endometriosi primitiva ombelicale. Caso clinico.

Umbilical primary endometrioma is a rare extra-uterine localization of endometriosis with a documented neoplastic risk. It is often difficult to distinguish primary umbilical endometriosis from other benign and malignant tumors of the abdominal wall. The Authors report a case of umbilical endometriosis in a 36-year old female. Endometriosis was suspected because of the presence of the typical cyclic bleeding and swelling. Abdominal CT excluded the presence of other endometriotic localizations. The umbilical mass was widely excised together with umbilicus, fascia and peritoneum. The tissue defect was primary closed without prosthetic mesh. Histological examination of the specimen showed the presence of endometrial glands with stromal component, compatible with the diagnosis of endometriosis. The Authors suggest that surgery should be performed in the first 3-4 days of the follicular phase, to minimize the risk of diffusion of endometriotic cells. Moreover, the excision should be wide in order to prevent local recurrence.

Laparoscopic trans-abdominal pre-peritoneal (TAPP) surgery for incarcerated inguinal hernia repair.

PURPOSE: This series was aimed to analyze feasibility, safety and postoperative quality of life of trans-abdominal pre-peritoneal repair in incarcerated hernia; the rationale was a safe hernia reduction, more accurate abdomen exploration, diagnosis and treatment of contralateral unknown hernia. METHODS: With a minimum follow-up of 30 months, 20 urgent incarcerated inguinal hernia patients were submitted to TAPP. Signs of strangulation, peritonitis and major comorbidity were exclusion criteria. Feasibility and safety were evaluated by ability to hernia reduction, conversion rate, operative time, perioperative mortality, morbidity, hospital stay, prosthesis infection and recurrence. Finally, quality of life was assessed by acute and chronic pain score, recovery of normal activities, return to work and patients' satisfaction survey. RESULTS: Under vision sac reduction was always achieved, incision of internal ring during the reduction manoeuvre was necessary in 40% of pts, intraoperative complications, conversions or perioperative mortality were not observed. In one case (5%) partial omentectomy was necessary. Contralateral hernia was diagnosed and repaired in 20%. Median operative time was 81.3 min, postoperative minor complications were recorded in 5 patients (25%), median in hospital stay was 2 days. After a median follow-up of 39 months, 1 patient recurred (5%). Acute pain, was scored 3 as median value (range 1-5), only one patient scored 2 as chronic pain during follow-up. CONCLUSIONS: Laparoscopic approach for incarcerated inguinal hernia repair is not the standard treatment. In our experience, with the limit of a single-surgeon series, selected patients showed satisfactory results in terms of feasibility, safety, postoperative quality of life and patients' satisfaction were observed. Few series about this topic were published. More prospective trials are needed.