Aorto-mesenteric compass syndrome (Wilkie's syndrome) in the differential diagnosis of chronic abdominal pain.

A woman in her 40s was admitted to hospital with weight loss, asthenia, persistent abdominal pain and post-prandial nausea and vomiting. Other comorbidities were anxiety-depressive disorder, gastro-oesophageal reflux disease and fibrocystic mastopathy. On admission her body mass index (BMI) was 15.57 kg/m2 with a reported weight loss of 6 kg during the last 3 months. The patient underwent a double contrast abdominal CT scan, which showed that the third portion of the duodenum appeared to be compressed between the superior mesenteric artery and the abdominal aorta. After a multidisciplinary evaluation, a conservative approach and nutritional supplementation was decided upon and administered. At the 1-year follow-up the symptoms had greatly improved; the epigastric pain, although persistent, was reduced, also due to the weight gain to 50 kg (BMI 19.5 kg/m2). Wilkie's syndrome, in its acquired form, predominantly affects young women after rapid weight loss. In the diagnostic work-up, case history, physical examination and radiological findings play a key role.

Low Potassium Intake: A Common Risk Factor for Nephrolithiasis in Patients with High Blood Pressure.

Hypertension (Htn) is a crucial cause of cardio-vascular and chronic kidney disease. Moreover, it is an independent risk factor for nephrolithiasis (NL). A diet rich in vegetables and fruits is indicated for both Htn and NL prevention, and the 24-h urinary potassium excretion can be used as a warning light for adherence. The aim of this study is to demonstrate the association between urinary potassium excretion and recurrent nephrolithiasis among patients affected by Htn. We have analyzed medical records of 119 patients affected by Htn and NL (SF-Hs) referring to Bone and Mineral Metabolism laboratory and 119 patients affected by Htn but without NL (nSF-Hs) referring to Hypertension and Organ Damage Hypertension related laboratory, both in Federico II University of Naples. The potassium 24-h urinary levels in SF-Hs were significantly lower compared to nSF-Hs. This difference was confirmed by the multivariable linear regression analysis in the unadjusted model and adjusted model for age, gender, metabolic syndrome, and body mass index. In conclusion, a higher potassium urinary excretion in 24-h is a protective factor against NL in patients affected by Htn and dietary interventions can be considered for kidney protection.

An inguinal bladder diverticulum Case report of a rare finding in a recurrent inguinal hernia.

We report a rare case of recurrent right inguinal hernia with bladder diverticulum incarcerated in a 63 years old male. Patient complained of painful swelling in inguinoscrotal region associated with urinary discomfort. Preoperatively diagnosis was made possible by ultrasound and urography imaging. Surgical treatment was achieved, by infra-umbilical incision, a reduction of the herniated and fixed diverticulum followed by a mesh repair of the wall defect. Patient was discharged five days after surgery and became free of symptomatology soon after surgical procedure. Bladder diverticulum involvement in a direct inguinal hernia is rare finding and define a potential pitfall for surgeon if not diagnosed preoperatively. There are no other cases of incarcerated bladder diverticulum incarcerated in a recurrent inguinal hernia described in Literature. KEY WORDS: Bladder diverticulum, Bladder hernia, Inguinal hernia.

Conventional (CH) vs. stapled hemorrhoidectomy (SH) in surgical treatment of hemorrhoids. Ten years experience.

INTRODUCTION: Interest about hemorrhoids is related to its high incidence and elevated social costs that derive from its treatment. Several comparative studies are reported in Literature to define a standard for ideal treatment of hemorrhoidal disease. Radical surgery is the only therapeutic option in case of III and IV stage haemorrhoids. Hemorrhoids surgical techniques are classified as Open, Closed and Stapled ones. OBJECTIVE: We report our decennial experience on surgical treatment focusing on early, middle and late complications, indications and contraindications, satisfaction level of each surgical procedure for hemorrhoids. METHODS: Four hundred forty-eight patients have been hospitalized in our department fom 1st January to 31st December 2008. Of these 241 underwent surgery with traditional open or closed technique and 207 with the SH technique according to Longo. This retrospective study includes only patients with symptomatic hemorrhoids at III or IV stage. RESULTS: There were no differences between CH and SH about both pre and post surgery hospitalization and intraoperative length. Pain is the most frequently observed early complication with a statistically significant difference in favour of SH. We obtain good results in CH group using anoderma sparing and perianal anaesthetic infiltration at the end of the surgery. In all cases, pain relief was obtained only with standard analgesic drugs (NSAIDs). We also observed that pain level influences the outcome after surgical treatment. No chronic pain cases were observed in both groups. Bleeding is another relevant early complication in particular after SH: we reported 2 cases of immediate surgical reintenvention and 2 cases treated with blood transfusion. Only in SH group we report also 5 cases of thrombosis of external haemorrhoids and 7 perianal hematoma both solved with medical therapy There were no statistical significant differences between two groups about fever, incontinence to flatus, urinary retention, fecal incontinence, substenosis and anal burning. No cases of anal stenosis were observed. About late complications, most frequently observed were rectal prolapse and hemorrhoidal recurrence, especially after SH. DISCUSSION AND CONCLUSION: Our experience confirms the validity of both CH and SH. Failure may be related to wrong surgical indication or technical execution. Certainly CH procedure is more invasive and slightly more painfull in immediate postoperative period than SH surgery, which is slightly more expensive and has more complications. In our opinion the high risk of possible early and immediate complications after surgery requires at least a 24 hours hospitalization length. SH is the gold standard for III grade haemorrhoids with mucous prolapse while CH is suggested in IV grade cases. Hemorrhoidal arterial ligation operation (HALO) technique in III and IV degree needs further validations.

Rives technique is the gold stardard for incisional hernioplasty. An institutional experience.

AIM: We report our clinical experience with incisional hernia surgery and we retrospectively analyze the outcomes obtained with the different techniques of repair used, confirming that Rives-Stoppa procedures actually represent the gold standard for incisional hernia. MATERIAL OF STUDY: 334 patients were observed for incisional hernioplasty at our Department of Surgery from 1996 to 2007. They were treated according to the following surgical procedures: 44 primary direct closures; 246 Rives-Stoppa procedures; 9 Chevrel procedures; 35 intraperitoneal repairs. The outcomes were considered in terms of postoperative surgical complications. RESULTS: In total, we had 13 cases of hernia recurrence (3.9%), 14 cases of infections (4.2%), 7 cases ofseroma/hematoma (2.9%) and one case of acute respiratory insufficiency. DISCUSSION: The choice of the surgical technique depends on several factors, such as the size of the hernia defect and the representation of the anatomical structures, essential for the reconstruction of the abdominal wall. We abandoned Chevrel technique due to high rate of recurrence and infective complications and reserved the intra-peritoneal repair only for cases where a fascial layer could not be reconstructed. Instead, the primary direct closure should be considered for high risk patients because of its low surgical impact, although it is characterized by higher incidence of recurrence. Combining the Rives-Stoppa technique with some personal technical modifications, we obtained acceptable results in terms of recurrence rate and morbidity. CONCLUSIONS: Rives-Stoppa procedures are the current standard of care for the surgical repair of incisional hernia and our treatment of choice.

Dietary chemoprevention of colorectal cancer.

AIMS AND BACKGROUND: Colorectal cancer is the second cause of morbidity and death in Italy. Genetic and environmental factors, i.e. inappropriate nutrition, are strongly involved in the aetiology of colon cancer. In the present review the authors analyze the possible mechanisms by which certain nutritive factors may interfere with the complex process of carcinogenesis. METHODS: The authors identify studies by a literature search of Medline from January 1, 1970, through December 31, 2006. RESULTS: The mechanism of every protective compound is detailed, in particular the impact of antioxidant vitamins and minerals on tumor development. At present, the data suggest that vegetables are associated with lower risk and that their fbre content alone does not account for this association. Further, meat consumption is associated with an increased risk but this, too, is not explained solely by its fat content. Several microconstituents of the diet may be associated with reduced risk, including folate, methionine, calcium and vitamin D. Short chain fatty acids also contribute to colonic health. Nevertheless agricultural products contain several dangerous pesticides. Mutagenic compounds, particularly heterocyclic amines, produced when protein is cooked, plausibly explain the meat association. CONCLUSIONS: Healthy nutrition is a necessary but not sufficient condition for colon cancer prevention: accepted the feasibility of an accurate control on every patient's diet, fequently the difficulty encountered in nutritional chemoprevention is to establish individual metabolic profiles.

[Current indications for the surgical treatment of pulmonary tuberculosis]. / Indicazioni attuali al trattamento chirurgico della tubercolosi polmonare.

A marked worldwide increase in the prevalence of pulmonary tuberculosis has occurred over the past 15 years. The reasons for this change include the worldwide epidemic of AIDS, poverty and the unprecedented extent of migration. We selected 47 patients with pulmonary tuberculosis or its sequelae for 51 surgical operations, with a high prevalence of subjects under 50 years of age (48.9%). There were three major non-fatal complications, and three minor complications. One patient died on postoperative day 1 as a result of unrelated causes. At present, surgery for tuberculosis of the lungs is mainly indicated when all medical treatments have proved ineffective or in circumstances where complete control of complications or disease sequelae is necessary, provided there is a correct indication and a flawless execution.

[Emergency surgical treatment of complicated acute diverticulitis]. / Trattamento chirurgico d'urgenza della diverticolite acuta complicata.

Twenty-five percent of patients undergoing surgery for acute complicated diverticulitis represent emergencies. This condition is currently treated by colonic resection with primary anastomosis with or without colostomy, or by a Hartmann operation. We report on our experience with 52 consecutive patients with generalized peritonitis (8 cases), peri- and paracolonic abscesses (19 cases), severe pelvic abscesses (12 cases) and multiple abscesses with visceral fistulas (13 cases). All patients had emergency surgery. In 50/52 patients (96.2%) we performed a colonic resection with primary anastomosis using a mechanical stapler and in 2/52 a Hartmann operation. The overall mortality rate was 5.8%. The morbidity rate was 22% with 9 anastomotic leakages. A diverting colostomy was constructed in 16 patients and opened in only 8 patients. In 4 cases a parastomal hernia occurred after late closure and reduction of the colostomy. This data suggest that colonic resection with primary anastomosis, even without colostomy, is a safe procedure for the emergency treatment of acute complicated diverticulitis.

[Lung resection: predictive value of respiratory function]. / Exeresi polmonare: predittività della funzione respiratoria.

The most important preoperative cardiopulmonary variables for identifying patients at increased risk prior to lung resection are: FEV1, FEV1-ppo, DLCO, MVO2, and SO2. The aim of this study was to evaluate the ability and usefulness of predictive postoperative FEV1 (FEV1-ppo) in 80 patients undergoing lung resection. Spirometry was performed before and 6 months after operation; residual respiratory function was calculated using Nakahara's formula, and data analysis calculations were performed using the chi 2 test. It was observed that the resulting predictive values were almost comparable to the values observed 6 months postoperatively in 63.75% of patients and the correlation proved statistically significant (P < 0.005). In view of its simple and rapid execution, we conclude that Nakahara's formula, compared with the others, remains a reliable standard method of assessing high-risk patients and planning appropriate surgery.