Reconstruction of Scrotal Sac and Penis with Biological Prosthesis and Vacuum Therapy.

Fournier's gangrene is a rapidly progressing necrotizing fasciitis, involving perineal, perianal, or genital regions, and it constitutes a true surgical emergency. Surgical excision of all necrotic tissue is required, and multiple debridements may be necessary to remove all nonviable tissue. After surgical intervention for debridement, reconstruction may be necessary. We present our experience in the treatment of tissue loss after Fournier's gangrene of genital and perianal regions with the use of biological mesh (derma porcine mesh) in association with vacuum-assisted closure therapy.

Quality of life after treatment of rectal intussusception or rectocele by means of STARR.

AIM: Stapled Transanal Rectal Resection (STARR) has been proposed for surgical treatment of rectal intussusception and rectocele. This study aims at evaluating the effect of the STARR on symptoms of obstructed defecation and associated faecal incontinence regarding the impact on the quality of life of patients with rectal intussusception and rectocele. MATERIALS AND METHODS: Twenty-nine patients with rectal intussusception and 22 with rectocele, who underwent to STARR in the General Surgery of the University of L'Aquila-Italy, are the subjects of the study. Symptoms of obstructive defecation were reported in all cases; with associated faecal incontinence in 31%. Questionnaires as ODS-Score, PAC-QoL, FISI and FIQL were proposed to all 51 patients before surgical treatment and at 3 years from operation. RESULTS: ODS-Score decreased from 28 ± 3.66 preoperatively to 6.7 ± 5.77 postoperatively ( p< 0.001), while PACQoL score was 14 ± 1.4 preoperatively vs 5.3 ± 1.7 postoperatively ( p<0.0020). The lower score indicates a lower severity index and an excellent quality of life. FISI score arose from 16.13 ± 5.39 before surgery to 19.33 ± 2.31 after surgery while, in the group of patients with preoperative symptoms of faecal incontinence, it arose from 7.86 ± 2.89 to 16.4 ± 4.5 after surgery (p< 0.0039). FIQL score sum was 105 ± 75 preoperatively vs 225 ± 90 postoperatively. The lower score indicates a higher severity index and a lower quality of life. CONCLUSIONS: Patients with rectal intussusception or rectocele may improve their symptoms and quality of life undergoing to the STARR.

Laparoscopic floppy Nissen fundoplication: 11-year follow-up.

BACKGROUND: There are few published reports on the outcomes of ≥ 10 years after a laparoscopic floppy Nissen fundoplication (LFNF). MATERIALS AND METHODS: From April 1994 to January 2012, 567 patients underwent LFNF and the outcomes of 211 cases were determined (from April 1994 to October 2000). RESULTS: Outcomes at ≥ 11 years after surgery was available for 178 patients (84.3%) of which 167 (93.8%) had no heartburn or mild heartburn, 8 (4.5%) had moderate heartburn, and 3 had (1.7%) severe heartburn. Dysphagia was nonexistent or mild in 153 (85.9%), whereas the remaining 14.1% presented moderate to severe symptoms. Reports of 69.1% patients showed none or mild symptoms of abdominal bloating, that of 23% patients showed moderate discomfort, and reports of 7.8% showed severe bloating. Satisfaction score was 8.6 (of 10). A further surgical procedure was required for 7 patients (3.9%): 4 for recurrent reflux and 3 for dysphagia (2 for a tight wrap and 1 for a tight esophageal hiatus). Postoperative dysphagia sufficient for an endoscopic dilatation was observed in 4 patients (2.3%), where 3 were successfully managed with a single dilatation procedure and the last patient underwent several dilatations before adequate swallowing. CONCLUSION: LFNF is an effective long-term treatment for gastroesophageal reflux disease, yielding similar results to open fundoplication.

The neutrophils response after laparoscopic and open cholecystectomy.

AIM: This study want to examine (a) whether neutrophils, the neutrophil-elastase, C-reactive protein and the Interleukin- 6 are modified and how, in patients after laparoscopic cholecystectomy open cholecystectomy; (b) whether these findings are indicative of an increased risk to develop infectious complications. MATERIALS OF STUDY: Circulating Interleukin-6 level, C-reactive protein and neutrophil-elastase were measured in 71 patients (35 underwent open cholecystectomy and 36 laparoscopic cholecystectomy). The diagnosis was confirmed by ultrasound examination. During hospitalization the patients were not given antispastic drugs, steroids, or nonsteroidal antiinflammatory drugs (NSAID). RESULTS: The increase in the serum Interleukin-6 and neurtophil-elastase, during laparoscopic cholecystectomy, was found to be significantly smaller than that during open cholecystectomy and resulted in a smaller extent of postoperative elevations for C-reactive protein. We recorded three cases (8.5%) of postoperative infections in the "open'" group and neutrophil- elastase values normalized later in patient with complications. CONCLUSION: There were significant associations between the response areas of Interleukin-6, C-reactive protein and neutrophil- elastase levels. Neutrophils-elastase level is a more sensible inflammatory marker in comparison to the IL-6 and C-reactive protein. Excessive and prolonged post injury elevations of these mediators are associated with increased morbidity.

Systemic inflammation and immune response after laparotomy vs laparoscopy in patients with acute cholecystitis, complicated by peritonitis.

AIM: To evaluate acute cholecystitis, complicated by peritonitis, acute phase response and immunological status in patients treated by laparoscopic or open approach. METHODS: From January 2002 to May 2012, we conducted a prospective randomized study on 45 consecutive patients (27 women, 18 men; mean age 58 years). These subjects were taken from a total of 681 patients who were hospitalised presenting similar preoperative findings: acute upper abdominal pain with tenderness, involuntary guarding under the right hypochondrium and/or in the flank; fever higher than 38 °C, leukocytosis greater than 10 × 10(9)/L or both, and ultrasonographic evidence of calculous cholecystitis possibly complicated by peritonitis. These patients had undergone cholecystectomy for acute calculous cholecystitis, complicated by bile peritonitis. Randomly, 23 patients were assigned to laparoscopic cholecystectomy (LC), and 22 patients to open cholecystectomy (OC). Blood samples were collected from all patients before operation and at days 1, 3 and 6 after surgery. Serum bacteraemia, endotoxaemia, white blood cells (WBCs), WBC subpopulations, human leukocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin-1 (IL-1) and IL-6, and C-reactive protein (CRP) were measured at 0, 30, 60, 90, 120 and 180 min, at 4, 6, 12, 24 h, and then daily (8 A.M.) until post-op day 6. RESULTS: The two groups were comparable in the severity of peritoneal contamination as indicated by the viable bacterial count (open group = 90% of positive cultures vs laparoscopic group = 87%) and endotoxin level (open group = 33.21 ± 6.32 pg/mL vs laparoscopic group = 35.02 ± 7.23 pg/mL). Four subjects in the OC group (18.1%) and 1 subject (4.3%) in the LC group (P < 0.05) developed intra-abdominal abscess. Severe leukocytosis (range 15.8-19.6/mL) was observed only after OC but not after LC, mostly due to an increase in neutrophils (days 1 and 3, P < 0.05). This value returned to the normal range within 3-4 d after LC and 5-7 d after OC. Other WBC types and lymphocyte subpopulations showed no significant variation. On the first day after surgery, a statistically significant difference was observed in HLA-DR expression between LC (13.0 ± 5.2) and OC (6.0 ± 4.2) (P < 0.05). A statistically significant change in plasma elastase concentration was recorded post-operatively at days 1, 3, and 6 in patients from the OC group when compared to the LC group (P < 0.05). In the OC group, the serum levels of IL-1 and IL-6 began to increase considerably from the first to the sixth hour after surgery. In the LC group, the increase of serum IL-1 and IL-6 levels was delayed and the peak values were notably lower than those in the OC group. Significant differences between the groups, for these two cytokines, were observed from the second to the twenty-fourth hour (P < 0.05) after surgery. The mean values of serum CRP in the LC group on post-operative days (1 and 3) were also lower than those in the OC group (P < 0.05). Systemic concentration of endotoxin was higher in the OC group at all intra-operative sampling times, but reached significance only when the gallbladder was removed (OC group = 36.81 ± 6.4 ρg/mL vs LC group = 16.74 ± 4.1 ρg/mL, P < 0.05). One hour after surgery, microbiological analysis of blood cultures detected 7 different bacterial species after laparotomy, and 4 species after laparoscopy (P < 0.05). CONCLUSION: OC increased the incidence of bacteraemia, endotoxaemia and systemic inflammation compared with LC and caused lower transient immunological defense, leading to enhanced sepsis in the patients examined.

Adenocarcinoma of the third duodenal portion: Case report and review of literature.

We focus on the diagnostic and therapeutic problems of duodenal adenocarcinoma, reporting a case and reviewing the literature. A 65-year old man with adenocarcinoma in the third duodenal portion was successfully treated with a segmental resection of the third part of the duodenum, avoiding a duodeno-cephalo-pancreatectomy. This tumor is very rare and frequently affects the III and IV duodenal portion. A precocious diagnosis and the exact localization of this neoplasia are crucial factors in order to decide the surgical strategy. Given a non-specificity of symptoms, endoscopy with biopsy is the diagnostic gold standard. Duodeno-cephalo-pancreatectomy (DCP) and segmental resection of the duodenum (SRD) are the two surgical options, with overlapping morbidity (27% vs 18%) and post operative mortality (3% vs 1%). The average incidence of postoperative long-term survival is 100%, 73.3% and 31.6% of cases after 1, 3 and 5 years from surgery, respectively. Long-term survival is made worse by two factors: the presence of metastatic lymph nodes and tumor localization in the proximal duodenum. The two surgical options are radical: DCP should be used only for proximal localizations while SRD should be chosen for distal localizations.

Idiopathic intramural hematoma of sigmoid colon. A case report.

Intramural hematoma of the colon is rare. It may be "spontaneous" in patients with anticoagulant therapy or blood dyscrasia or caused by blunt abdominal trauma. An uncertain origin is also reported, so we have also "idiopathic hematoma". The AA report a new case of uncertain origin and review the literature. The diagnosis is difficult. Symptoms and signs of intestinal obstruction or colic bleeding are often present. Rx plain abdomen and colonoscopy are not diriment. Angio-TC is useful for detailed diagnosis. Resection of colic segment with hematoma is the gold standard therapy, but evacuation of hematoma might be considered. The reported data show that also colic intramural hematoma should be taken into account in cases of colic obstruction or bleeding. This diagnosis should be considered specially in patients with anticoagulant therapy or referred blunt abdominal trauma.

Cholecystectomy for gallbladder disease in elderly aged 80 years and over.

BACKGROUND/AIMS: Patients aged 80 years and over show greater risk of complicated gallbladder diseases and associated comorbidities. The aim of the study is to evaluate the prognosis after laparoscopic or open cholecystectomy in these patients. METHODOLOGY: 100 patients aged between 80 and 92 years (group 1) and 241 patients aged between 70 and 79 years (group 2), undergoing cholecystectomy for gallbladder disease, are the subject of the study. Types of disease and surgery and p.o. morbidity and mortality have been evaluated. RESULTS: The patients of group 1 have shown a significant greater incidence of p.o. morbidity (20%) than group 2 (2.3%) (chi2 = 39.5; p < 0.001), regardless to the type of cholecystectomy. Endoscopic sphincterotomy for lithiasis of common biliary duct seems an important risk factor (chi2 = 7.1; p < 0.001). In group 2, the morbidity rate after laparoscopic cholecystectomy was lesser than after open surgery (X2=5.3; p < 0.02). In both groups, postoperative hospital stay was longer after open cholecystectomy and endoscopic sphincterotomy. CONCLUSIONS: Patients aged 80 years and over, undergoing cholecystectomy, specially after endoscopic sphinterotomy., have a greater risk of p.o. morbidity and mortality than younger. Laparoscopic and open cholecystectomy seems to bear the same poor p.o. prognosis.

Multidisciplinary day surgery unit: seven years' experience.

The autonomous multidisciplinary day surgery unit is the gold standard for day surgery procedures. The Authors report their experience with the Pescina Hospital autonomous multidisciplinary day surgery unit (Avezzano Heath Authority, University of L'Aquila). In total, 4140 patients were enrolled to the day surgery setting from 2001 to 2007. Age, gender and ASA of patients, type of disease, surgery, anaesthesia and the usual day surgery activity quality indices (cancellation and delays of operations, postoperative pain and nausea or vomiting, postoperative morbidity, discharge and early readmission) were evaluated. 4046 patients underwent day surgery (orthopaedic 29.8%, general surgery 26.2%, ophthalmology 21.6%, vascular surgery 19.8%, miscellaneous 2.6%). Rates of cancelled and delayed operations were 2.3% and 2.4%, respectively. Local anaesthesia was performed in 54.3% of operations. None of the patients reported postoperative nausea and vomiting. Severe postoperative pain was present in 10% of cases. 77% of patients was discharged within four hours of surgery, and the others within six hours. Four patients (0.11%) were readmitted early. The postoperative morbidity and mortality rates were 0.49% and 0%, respectively. None of the postoperative events correlated with gender, age, ASA, or type of surgery and anaesthesia. The multidisciplinary day surgery unit, with dedicated medical and nursing staff and suitable organisation such as ours is characterised by favourable surgery activity quality indices and good patient outcomes.

Acute ischaemic colitis: outcome in elderly patients.

The Authors report the results of the management of ischaemic colitis in a surgical unit dedicated to elderly patients. Sixty-two elderly patients affected by ischaemic colitis were observed consecutively in the Surgery Unit of the University of L'Aquila from 1986 to 2004. The clinical records of the patients were retrospectively reviewed in order to assess clinical, biohumoral, endoscopic and x-ray findings pre- dictive of the most suitable type of treatment. Clinical follow-up was performed to evaluate the long-term prognosis after a mean period of 8 years post-treatment. Forty-six patients (74.1%) were treated by medical therapy only for a mean period of 7 days with a positive outcome and no mortality. Sixteen patients (25.9%) underwent surgery. Postoperative morbidity and mortality rates were 62.5% and 43.7%, respectively. Absence of bowel sounds (chi2 = 61.9, p < 0.001), ileus (chi2 = 17.8, p < 0.001) and air fluid levels in plain abdominal x-rays (chi2 = 18.6, p < 0.001) were risk factors for surgery. At follow-up a favourable outcome, without findings of recurrent acute or chronic ischaemic colitis, was observed in 55 patients. In conclusion, the results seem to suggest that medical therapy is the mainstay of treatment for acute ischaemic colitis in elderly patients with good clinical results. Peritonitis is an indication for surgery.

Spontaneous hematoma of the mesocolon.

Spontaneous hematoma of the mesocolon is a rare condition, mainly due to the rupture of a colic artery aneurysm. The authors report on two cases of spontaneous hematoma of the mesocolon and examine the relevant literature. The clinical presentation in our patients was, as indicated in the literature, non-specific, with the occurrence of acute abdomen (case 1) or mild abdominal pain (case 2). Only diagnostic imaging (contrast-enhanced CT scan) is capable of yielding an accurate diagnosis, specifying the size and location of the hematoma. A palpable mass or hemoperitoneum due to rupture should be regarded as late signs of presentation. Early diagnosis is of the utmost importance in order to avoid the by no means negligible mortality reported in such instances or ischaemic bowel wall complications.

Is there a place for intraperitoneal onlay mesh repair (IPOM) of inguinal hernia among laparoscopic techniques?

BACKGROUND/AIMS: The Authors report their experience on laparoscopic hernioplasty using the intraperitoneal onlay mesh repair in 56 patients. METHODOLOGY: Thirty patients had a monolateral hernia, 9 of which were recurrent and 26 had a bilateral hernia, 6 of which were recurrent. Overall, a total of 90 hernias were treated. The hernia repair was performed by using "GORETEX Dual Mesh Plus biomaterial with holes" in the first 32 cases and the latest "Corduroy" type in the following 24 cases. The prostheses were fixed with titanium spiral tacks (Protack, Auto Suture, Tyco Healthcare). RESULTS: No intraoperative complications occurred and no conversion was necessary. Five minor postoperative complications (5.5%), 2 seromas and 3 transient paresthesias, were observed. Four patients (7.1%) needed analgesics after the first 24 hours. Mean hospital stay was 36 hours with a minimum of 24 and a maximum of 48. Mean resumption of normal activity was 8 days with return to work within two weeks. At an average 18 months follow-up, 3 recurrences were recorded (3.3%). CONCLUSIONS: The results of this study as well as the meta-analysis of the series presented in the literature, indicate that the intraperitoneal onlay mesh repair may be a feasible, safe and effective procedure in the treatment of recurrent and bilateral hernias or when a hernia repair is performed during other laparoscopic procedures. The intraperitoneal onlay mesh repair has in fact been shown to be faster and easier than the other more commonly performed laparoscopic hernioplasties (trans-abdominal preperitoneal repair and total extra-peritoneal repair). These data may also suggest utilizing this technique in particular cases of primitive hernia such as very active young males or heavy-duty workers. However the limited series and the short follow-up ask for randomized prospective long-term studies to definitely ascertain the true incidence of recurrence and therefore the effectiveness of this attractive procedure.

[Postoperative pain as complication of hernia surgical repair with mesh and plug]. / Il dolore postoperatorio come complicanza dell'ernioplastica inguinale con mesh e plug.

The authors assess the incidence of locoregional chronic pain after inguinal hernia repair. One hundred consecutive patients, with a mean age of 65.4 years, suffering from primary monolateral inguinal hernia, underwent suture-less mesh-plug hernioplasty. In all cases the inguinal nerves were identified. In the early postoperative period, a questionnaire was given to all patients in order to assess the frequency, type and intensity of postoperative locoregional pain and the impact of the pain on their quality of life. Sixty patients were available for follow-up with clinical examination and these were given the same questionnaire 2-4 years after hernioplasty. Pain intensity was scored by means of a visual-analogue scale (from 0 to 10). The incidence of locoregional pain after hernioplasty was 13.0% in the early postoperative period and 25.0% after a longer period of follow-up. None of the patients presented recurrent hernia. The symptomatic patients reported mild or moderate neurogenic pain. Severe pain was not reported. On the whole, the presence of mild-to-moderate chronic pain had no impact on the patients' quality of life. Our study confirms the high incidence of locoregional chronic pain even after sutureless mesh-plug hernioplasty, but that this has no serious effects on the patients' quality of life.