Recurrent incisional hernia, enterocutaneous fistula and loss of the substance of the abdominal wall: plastic with organic prosthesis, skin graft and VAC therapy. Clinical case.

Surgical wounds dehiscence is a serious post-operatory complication, with an incidence between 0.4% and 3.5%. Mortality is more than 45%. Complex wounds treatment may require a multidisciplinary management. VAC Therapy could be an alternative treatment regarding complex wound. VAC therapy has been recently introduced on skin's graft tissue management reducing skin graft rejection. The use of biological prosthesis has been tested in a contaminated field, better than synthetic meshes, which often need to be removed. The Permacol is more resistant to degradation by proteases due to its cross-links. Surgery is still considered the best treatment for digestive fistula. A 58 years old obese woman come to our attention, she was operated for an abdominal hernia. She had a post-operatory entero-cutaneous fistula. She was submitted to bowel resection, the anastomosis has been tailored and the hernia of the abdominal wall has been repaired with biological mesh for managing such condition. She had a wound dehiscence with loss of substance and the exposure of the biological prosthesis, nearly 20 cm diameter. She was treated first with antibiotic therapy and simple medications. In addiction, antibiotic therapy was necessary late associated to 7 months with advanced medications allowed a small reduction's defect. Because of its, treatment went on for two more months using VAC therapy. Antibiotic's therapy was finally suspended. The VAC therapy allowed the reduction of the gap, between skin and subcutaneous tissue, and the defect's size preparing a suitable ground for the skin graft. The graft, managed with the vac therapy, was necessary to complete the healing process.

Multiorgan female pelvic prolapse: pelvic organ prolapse suspension (P.O.P.S.) stapled transanal rectale resection (S.T.A.R.R.): new surgical tecniques and results.

AIM: To demonstrate the surgical treatment validity and the post-operative complication decrease. MATERIAL OF STUDY: Seventythree women who underwent P.O.P.S. + S.T.A.R.R. treatment, follow-up one year. RESULTS: We observed an important reduction or a completely disappearance about pre-operative signs and symptoms. DISCUSSION: We are aware that the proposed technique, if taken into account by urogynecologists, will raise several arguments and will raise many doubts and perplexities. For this reason we wanted develop a follow-up sufficiently long and many case studies with data to support our claims. CONCLUSIONS: We believe that the procedure proposed by us, given the results, was excellent in patients with multiorgan pelvic prolapse, especially with the vagina walls elongated and that retain a good trophism.

Long-term outcome of stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids.

PURPOSE: This study was designed to assess the long-term results of stapled hemorrhoidopexy in 291 patients with Grade III and Grade IV hemorrhoids after a minimum follow-up of five years. METHODS: Records of patients submitted to stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids between January 1999 and December 2002 were retrospectively analyzed. Long-term outcome was evaluated with a standardized questionnaire and an office visit, including anorectal examination and rigid proctoscopy. RESULTS: A total of 291 patients with Grade III (57.4 percent) and Grade IV (42.6 percent) hemorrhoids were evaluated. Intraoperative (20.3 percent) and postoperative (4.8 percent) bleeding was the most frequent complication. The questionnaire was submitted to all patients at a median follow-up of 73 (range 60-93) months. There were no symptoms related to hemorrhoids in 65.3 percent of patients, moderate symptoms in 25.4 percent of patients, and severe symptoms in 9.3 percent of patients. Fifty-three (18.2 percent) patients had recurrence. Reoperation was necessary in 21 (7.2 percent) patients (4 in Grade III hemorrhoids and 17 in Grade IV hemorrhoids; P < 0.001), with no recurrent symptoms and/or prolapse. Patient satisfaction for operation was 89.7 percent. CONCLUSIONS: Stapled hemorrhoidopexy is a safe and effective treatment for Grade III and Grade IV hemorrhoids. Recurrence requiring reoperation was higher in Grade IV hemorrhoids than in Grade III hemorrhoids.

[The surgical treatment of neoplastic colorectal occlusions]. / Il trattamento chirurgico delle occlusioni neoplastiche colo-rettali.

The emergency treatment for neoplastic occlusions of rectum still needs debugging. While we finds perfect accord in to directly treat with a right hemicolectomy (more or less widened) the tumours from cecum to the first portion of the right colon, not the indications are likewise shared in presence of neoplastic stenosis of sigma-rectum. The treatment of urgency of these tumours is lent to so many variable and the tendencies too are constantly in evolution in relationship to the improvement of the technologies and the surgical devices. We have to chose from the two-three times intervention (now with less succession), or the total or subtotal colectomy otherwise the most used left hemicolectomy and anterior resection for sigmoid colon. Presenting our historical cases of 31 years of activity (Institute of Surgical Emergency Department--University La Sapienza of Rome), 564 neoplastic occlusions of the colon (75.7% sigma-rectum), the Authors describe their attitude both of approach and of surgical therapy in urgency that has brought them to practise in the 65.6% of the cases the anterior resection without protection colostomy, with extraperitoneal anastomosis and reconstitution of the pelvic peritoneum, in all the stenosis under descendant--sigma. In the last period it is frequent more and more the tendency to the positioning of a stent on the neoplastic stenosis: this treatment allows us to overcome the emergency to operate then under fitter conditions.

[Pathophysiological and clinical trials of the abdominal compartment syndrome]. / Fisiopatologia e clinica della sindrome compartimentale addominale.

The abdominal compartment syndrome (ACS) is defined a situation of high degrade abdominal hypertension (IAH) with clinicals signs of multiorganic dysfunction. It's observed like in the intensive care, in particular surgycals and postraumatics, there is ever a bigger frequence of complications presented by criticals patients. The various trials remark a changeable incidence, but the common factor is characterized by a particular severity of scores. All the possibles mechanicals, haemorragicals, infiammatories, and postraumatics causes act, but don't enable the stability among abdominal content, abdominal compliance and parietal tension. The initial triad of effects is constitued by the elevation of diaphragm and the visceral and vascular compression; after this triad provoke a pathophysiologic system that, through various levels, bring to a respiratory, renal and cardiocirculatory dysfunction and to a parietal, hepatic and intestinal ischemia with consequent bacterical translation: sepsis and MOF. The Burch's classification (1996) report four levels of gravity by the slight (< 15 mmHg) to the heavyest (> 35 mmHg): the firsts two levels are of intensivistic competence and for the detention are used conservatives metodics and pharmacological approach; instead in the lasts two levels it's necessary to foresee a surgycal treatment of laparotomy, washing and drainage with following temporary paret's closure. The mortality is now very elevated (29-62%) especially when it's already established a multiorganical dysfunction; therefore it's necessary forward its appearance through the monitorization of abdominal pression (IAP) with the measurement of vescical pression in alls criticals patients at the aim to treat immediately the firsts signs of IAH.

[Colon lesion for blunt trauma in the abdomen]. / Le lesioni del colon da trauma chiuso dell'addome.

Colon lesions resulting from blunt trauma in the abdomen can be defined as infrequent. Actually, they represent 3-5% of all hollow organ trauma. They present, however, serious social burden because of its prevalence in males with medium age ranging from 40 to 70 years. Study was conducted from 1971 to present at the University of Rome "La Sapienza" Institute of Clinical Emergency Surgery. 42 cases were observed in which 72% had motor vehicle accidents (with less than 1/4 of these resulting from seat belt). Numerous lesions were associated, especially in the abdomen (31), and the skull (20), both with Medium OIS 4.2. Most part of the cases was within the OIS-Class III category. The clinical parameters recorded upon admission revealed particular serious situations with average values of SAP-92 mm Hg, HR-114, RR-28, GCS-12, RTS-10.8. 17% had shock upon arrival with unsuccessful resuscitation. Ultrasound results at emergency indicated 62% with effusion/major parenchymal lesion, and 22% with severe peritonitis. 41% were treated with direct suture, 26% with resection-anastomosis, 19% with primary Hartman resection, and 14% with simple colostomy. 24% had abdominal complications including 14% sepsis, 5% hemorrhage, and 2 cases of post-surgical caval thrombus. The overall mortality was 26%. In general these lesions were frightening because of their uncertain manifestations. In most instances clinical signs related to associate lesions are overlooked, and these often present late symptoms from 24 to 48 hours. Delayed treatment for untimely diagnosis is one of the yet prevailing complications. The methods of surgical repair depend on the timing, the nature of associated lesions and, above all, eventual peritoneal contamination. The primary treatment involves surgical option actually recommended according to the EAST guideline with specific preference of reconstruction using the primary principle, and resorting to earlier interventions only in the presence of associated critical factors.