Can herniation pit of the femoral neck mimic an acute appendicitis? A case report.

Although in most cases the diagnosis of acute appendicitis is straightforward, not all patients experience typical symptoms and other conditions may mimic appendicitis. In fact, 15-25% of appendectomies involve the removal of a normal appendix. To date, there is no literature evidence that herniation pit (HP) may mimic acute appendicitis. We report a case of a 30 year old woman admitted to the Emergency Department for severe, acute pain developing a few hours earlier in the lower right fossa, with irradiaton to the right thigh. She did not present any fever, nausea or vomiting, Blumberg's sign was absent but the psoas sign and obturator sign were both positive. WBC count was 16,000/mm3 and the Alvarado score was 4. Biochemistry profile was normal. US was unclear and transvaginal ultrasound did not show any gynecological disease. CT scan showed only an herniation pit of the right femoral neck. The patient was admitted to an orthopedic ward and treated with anti-inflammatory therapy. She was discharged after 2 days without any pain and in good conditions. Our case demonstrates that herniation pits of the right femoral neck should be considered a potential cause of right lower abdominal pain mimicking acute appendicitis, particularly if the psoas sign and obturator sign are positive and the patient is physically active.

[Overexpression of laminine-5( LN-5) in peritoneal lavage of colorectal cancer patients preliminary results]. / Overexpression della laminina-5 (LN-5) nel lavaggio peritoneale di pazienti con carcinomi del grosso intestino. Risultati preliminari.

Recent studies show that interaction between LN (heterotrimeric protein formed by a3/b3/g2 chains) and cancer cells plays an important role in tumor invasion, also in colorectal cancer. The overall survival was significantly worse in patients with free peritoneal cancer cells(FPTCs): detection of FPTCs after curative surgery is a challenge, because could improve staging and prognosis. Peritoneal citology is the current standard procedure with very low sensivity. We aimed to study the expression of LN5 in the peritoneal lavage of colorectal cancer pts and in controls with semiquantitative reverse trancriptase-polymerase chain reaction (RT-PCR). LN-5 overexpression was evaluated observing PCR- products intensity at electrophoresis: high intensity is correlated to overexpression. Pre and post-operative peritoneal lavages of 30 pts with colorectal cancer (13M;17F), with median age of 69 (58-84), and of 10 controls, were analyzed by conventional cytology and a semiquantitative RT-PCR. No cancer pts showed pre/postoperative negative cytology and did not express LN-5. In cancer pts. cytology was positive in 2 pts in pre/postoperative lavage. LN-5 overexpression was observed in 56,6% preoperatively and in 76,6% postoperatively. LN-5 g 2 chain was most frequent chain. Our study suggests a relationship between LN-5 and FPTCs, as shown by the low expression of lamimine in controls. LN-5 could be a useful marker to identify a subgroup of early-stage patients at increased risk of recurrence; moreover, mortality seems to correlated to LAMB3 chain. The diagnostic accuracy could be improved by using a quantitative RT-PCR or western-blot and detecting serum laminine. Finally, to validate these findings a larger number of pts with follow-up study is required.

Chilaiditi's syndrome. Successful surgical correction by colopexy.

We describe the case of a patient affected by the Chilaiditi's syndrome, the interposition of the small or large bowel between the inferior face of the diaphragm and the liver, a rare anomaly, often asymptomatic. A 50-year-old man came to our outpatients clinic because of persistent pain in the right abdominal region. Two attempts to perform colonoscopy failed because of the impossibility of passing through the transverse colon. A double contrast enema indicated only sigmoid diverticulitis. Only after abdominal radiography was the abnormal position of the right colon noted. At surgery the right colon was totally intraperitoneal and positioned between the diaphragm and liver, which was smaller than normal. The right colon was repositioned and fixed to the anterior abdominal wall. The postoperative course was uneventful and the right abdominal pain disappeared completely. In conclusion, surgical treatment of Chilaiditi's syndrome may be required in cases of persistent abdominal pain.

[Type of surgical articles. Comparative study of 3 Italian and 3 foreign periodicals]. / Tipi di articoli chirurgici. Analisi comparativa di tre periodici italiani e tre periodici stranieri.

BACKGROUND: Medical progress in the world is divulged to peers and colleagues through books and scientific journals. It is thus linked not only to the quality of articles, but also to their type. MATERIAL AND METHODS: The type of articles published in three Italian periodicals (Annali Italiani di Chirurgia; Chirurgia; Minerva chirurgica) and three foreign periodicals published in English (Annals of Surgery; British Journal of Surgery; Surgery, Gynecology & Obstetrics) was compared. The articles were classified according to their potential contribution to medical progress, being divided into two main groups: research papers and simple case series or case reports. Other types of articles (reviews, description of surgical techniques, editorials etc.) were excluded from the study. RESULTS: Both the total number and the percentage of research papers were markedly superior in the three foreign journals with respect to the three Italian periodicals. All the differences were highly significant. CONCLUSIONS: The number of research papers published in Italian periodicals should be increased. Greater attention should be paid to quality, at the expense of quantity, since serious research inevitably takes longer to perform.

The familial adenomatous polyposis region exhibits many different haplotypes.

In the present study, we used five different polymorphic markers to construct the haplotype at the adenomatous polyposis coli (APC) locus in families with familial adenomatous polyposis (FAP) and in the normal Italian population. Non-ambiguous haplotypes were reconstructed from 246 normal chromosomes and 65 FAP chromosomes. In the control population, the four polymorphisms intragenic to APC gave rise to 16 haplotypes, the most common of which (II and XV) accounted for over 50% of all chromosomes. In FAP patients, 13 haplotypes were found but their distribution was not statistically different from normal subjects. Eighty complete chromosomal haplotypes (many fewer than the theoretical maximum of 208) for the five polymorphic sites assayed were observed in the control population, 35 being found in the FAP patients. We compared the distribution of these haplotypes within the two groups; no statistically significant differences between normal and FAP chromosomes were found. The elevated heterogeneity of FAP chromosomes was clearly confirmed by the observation that 19 patients who carried one or other of the two most common APC mutations (nt 3183 and nt 3927) showed 18 different haplotypes. On the basis of these results, we were not able to identify a founder FAP chromosome. Various mechanisms are presented to explain this observation.

Is pyloric function preserved in pylorus-preserving pancreaticoduodenectomy?

OBJECTIVE: To assess the function of the pylorus after pylorus-preserving pancreaticoduodenectomy (PPPD) done for periampullary or pancreatic cancer. DESIGN: Prospective, observational controlled clinical study. SETTING: Teaching hospital, Italy. SUBJECTS: 17 patients who had undergone PPPD, and 15 healthy control subjects. INVESTIGATIONS: Endoscopy to check for gastritis and marginal ulcers and 24 h-pH monitoring and 99mTc HIDA scintigraphy to detect jejunogastric reflux. Scintigraphy was also used to evaluate gastric and jejunal transit after a solid meal labelled with 99mTc colloid sulphur. MAIN OUTCOME MEASURES: Signs of delayed gastric emptying, jejunogastric reflux and gastric outlet obstruction in the short and long term. RESULTS: In the early postoperative period only 1 patient had delayed gastric emptying. In the long term, two patients had symptoms of dyspepsia and 8/11 showed alkaline reflux with persistent gastric pH more than 4 for more than 12 hours; 3 had histological signs of gastritis. There was no difference in gastric emptying compared with controls, but three patients had prolonged emptying time (T1/2 more than 85 minutes). Endoscopy findings correlated with pH monitoring results. CONCLUSIONS: After PPPD, most patients have abnormal pyloric function, but it is clinically evident in only a small proportion.

Electrostimulated gracilis neosphincter for faecal incontinence and in total anorectal reconstruction: still an experimental procedure?

The possibility of converting an easily fatiguable muscle like the gracilis muscle into a fatigue-resistant one using chronic electrostimulation has renewed interest in Pickrell's procedure. Between July 1991 and June 1996, 9 patients (2 M; 7 F) mean age = 45 y (range 14-72) underwent dynamic graciloplasty using Medtronic electrostimulators. Five patients had faecal incontinence (2 congenitally anomaly, 1 neurological, 2 post-operative) and 4 had a perineal colostomy performed either simultaneously (two cases) or at 3 to 4 years after abdominoperineal excision of the rectum. Early post-operative complications included distal tendon necrosis [1], perineal colostomy breakdown [1], detachment of the gracilis tendon [2] and seroma in the thigh [1]. Long-term complications included rectocele with faecal impaction in one patient with imperforate anus, anal stricture in one patient who had refashioning of a perineal colostomy, and displacement of the lead from the main nerve in 3 with external expulsion in 2. The patient with anal stricture was successfully treated with anoplasty but subsequently returned to an abdominal colostomy due to stricture recurrence 2 years later. The rectocele was successfully treated using a transvaginal approach. Electrical conversion of the muscle was completed in all patients but long term functional results are available for only 5 cases. Manometry revealed a significant improvement in anal pressure under electro-stimulation and the continence grading scale score significantly improved in 4 patients. The technique is applicable to a very selected group of patients with no other options but is still in the experimental phase and should not be performed outside controlled trials. Repeated hospitalisation and reoperations are often required although the complication rate may diminish and improve with experience.

Vaginal repair of rectocele after dynamic graciloplasty for fecal incontinence due to imperforate anus.

A 35-years-old woman developed obstructed defecation due to a large (6 cm) non-emptying rectocele one year after successful electrostimulated gracilis neosphincter operation for correction of fecal incontinence after surgery for imperforate anus. Surgical correction of the rectocele was performed by a trans-vaginal approach due to the poor elasticity of the neoanus and avoidance of possible damage to the neosphincter. After physiological investigations, including defecography, the patient had a resection of the posterior vaginal mucosal wall, a double layer plication of the muscular wall with non-absorbable suture and a longitudinal mucosal suture. The postoperative course was uneventful. Defecography, performed 3 and 6 months later, showed a marked reduction of the rectocele (2 cm) which corresponded to clinical improvement. Occurrence of disabling rectocele can be considered a possible long term complication after successful electrostimulated neosphincter procedure in patients at risk for developing a rectocele; a successful repair can be obtained using trans-vaginal approach without the risk of neosphincter damage. Transvaginal repair of rectocele in similar clinical situations may be recommended.

Improved accuracy of computed tomography in local staging of rectal cancer using water enema.

A new technique in the preoperative staging computed tomography of rectal cancer using a water enema to promote full distension of the rectum was compared with standard CT in a non-randomised blind study. One hundred and twenty-one patients were enrolled. There were 57 in the water enema CT group and 64 in the standard group. The stage of the disease was assessed following strict criteria and tested against the pathological examination of the resected specimen. Water enema CT was significantly more accurate than standard CT with an accuracy of 84.2% vs. 62.5% (Kappa: 0.56 vs. 0.33: Kappa Weighted: 0.93 vs. 0.84). The diagnostic gain was mainly evident in the identification of rectal wall invasion within or beyond the muscle layer (94.7 vs. 61). The increased accuracy was 33.7% (CL95: 17-49; P < 0.001). The results indicate that water enema CT should replace CT for staging rectal cancer and may offer an alternative to endorectal ultrasound.

Reduction of postoperative immunosuppression with ranitidine in patients with cancer of the stomach or large bowel.

OBJECTIVE: To assess the effect of ranitidine on cellular immune response (and postoperative infective morbidity) in a homogeneous group of patients. DESIGN: Prospective randomized controlled trial. SETTING: University hospital, Italy. SUBJECTS: 42 patients about to undergo curative resection for carcinoma of the colon, rectum, or stomach. INTERVENTIONS: Cell mediated immunity was tested 3 days before, and 4 days after, operation by reactions to 7 recall antigens (Multitest, Merieux). 21 patients were randomly allocated to receive ranitidine 100 mg twice daily intravenously from the day before operation until the third postoperative day. MAIN OUTCOME MEASURES: Comparison of the number of reactive patients and number of positive antigens before and after operation; and correlation between reactivity and incidence of postoperative infective complications. RESULTS: The median (range) skin test scores preoperatively were: ranitidine group 8.5 (0-17), and control group 10 (0-19). The postoperative figures were 7 (0-28) and 4.5 (0-15.5) respectively. The corresponding numbers of positive antigens were 1 (0-4) and 3 (0-4) compared with 1 (0-5) and 1 (0-3). The changes in the scores did not seem to be influenced by blood transfusion, serum albumin concentration, age of the patient, or type of tumour. Two patients died in the ranitidine group (pulmonary embulus, n = 1, necrotising pancreatitis, n = 1) and there were 4 wound infections. There were no deaths in the control group, one intra-abdominal abscess, and 8 wound infections. Median hospital stay was similar, 10 (8-16) in the ranitidine group, and 11 (5-20) in the control group. CONCLUSION: Ranitidine had a beneficial effect on cell-mediated immunity as it seemed to prevent the usual postoperative reduction in reactivity, but there was no significant difference in the incidence of infective complications though it was lower in the ranitidine group.

Change in bioelectrical impedance following laparoscopic and open abdominal surgery.

The effect of surgery, and in particular, the relative effects of open and laparoscopic abdominal surgery on whole body bioelectrical impedance (BI) has been investigated. Repeated measurements of BI were performed over a 60 h period in 12 patients undergoing laparoscopic surgery (group A) and in 12 patients undergoing elective open abdominal surgery for benign conditions (group B). Control measurements were performed upon 4 healthy adult subjects over the same time period. Attempts were made to relate postoperative changes in BI in group A and group B to changes in net postoperative fluid balance. The postoperative disturbance in BI was significantly greater in group B than group A (P < 0.001 Mann-Whitney-U test) and differed significantly from the minor fluctuations of BI observed in the control group (P < 0.001 Mann-Whitney-U test). The fluctuations in BI observed after laparoscopic surgery were not significantly greater than those seen in the control group (P = 0.1 Mann- Whitney U test). Changes in BI in both group A and B did not correlate with changes in net postoperative fluid balance, which suggests that the effect of surgery upon BI was related to changes of body water distribution rather than changes in total body water volume.

Reliability of clinical judgement in evaluation of the nutritional status of surgical patients.

The ability of surgeons to make a reproducible and reliable evaluation of the nutritional status of patients was assessed. Three independent observers assigned 64 patients to one of four nutritional states--normal nourishment, and mild, moderate and severe malnutrition--using a questionnaire and clinical examination. Interobserver variability was analysed using the kappa statistic and reliability by assessing the correlation between the assigned class and total serum protein, haemoglobin, albumin, transferrin and cholesterol levels, weight loss and the results of immunological skin tests. Concordance was observed in 49 of the 64 judgements (77 per cent) and partial agreement in the remainder (kappa = 0.74, P < 0.001). Clinical judgement correlated significantly with albumin, transferrin and cholesterol levels and weight loss (R2 = 0.73, P < 0.001). Surgeons are able to assess nutritional status using clinical judgement.

Rectal carcinoma: CT staging with water as contrast medium.

Computed tomography (CT) was used to study 42 patients with rectal carcinoma. Water was used as a contrast medium for studying the local extent of tumor in all patients. Scans were read prospectively without knowledge of the histologic staging and then compared with pathologic specimens. CT depicted the tumor in all patients. Comparison of CT and histologic results (following the Dukes classification) showed that disease was correctly staged as A in three of four patients, as B in eight of 12, as C in 15 of 17, and as D in nine of nine. Overall, carcinoma was correctly staged with CT in 35 of 42 patients (diagnostic accuracy, 83.3%). The accuracy in the assessment of local invasion was 97.6% (41 of 42). In the detection of lymph node involvement, the accuracy was 78.6% (sensitivity, 88%; specificity, 64.7%). CT is recommended in the preoperative staging of rectal carcinoma and as an aid in choosing the appropriate therapy. The use of water enema and complete distention of the rectum are reliable techniques for improving the accuracy of CT in the assessment of local invasion by cancer.

Protective colostomy closure: the hazards of a "minor" operation.

A retrospective study of 87 patients, subjected to colostomy closure between 1976 and 1987, was conducted in order to evaluate the role of 8 potential risk factors on morbidity and mortality. Possible risk factors were age greater than 65 years, presence of hypoalbuminaemia (less than 3.0 gr%), anaemia (Hb less than 10 gr%), operative technique, duration of colostomy, site of colostomy, underlying disease and presence of subcutaneous drainage. Apart from hypoalbuminaemia, no clear risk factor was identified, although an interval of more than 90 days between construction and closure of colostomy appears to be safer than shorter intervals. A comparison was also made between two different periods from 1976 to 1982 and from 1983 to 1987 which resulted in important changes in patient management in the second period including: type of antibiotic prophylaxis, type of anastomosis and suture material, site of colostomy and mean duration of colostomy. Four post-operative deaths (4.6%) (two for myocardial insufficiency and two for sepsis), 11 major (13%) and 25 (29%) minor complications were recorded. The analysis of the two different periods showed a strong reduction in both mortality and morbidity in the second period, which could be related to a better management of this type of patient. In conclusion, the incidence of mortality and morbidity in colostomy closure cannot be underestimated and therefore the same skill and meticulous approach are required for this operation as for any major surgical procedure on the colon.

Prediction of mortality by logistic regression analysis in patients with postoperative enterocutaneous fistulae.

The contrasting results of treatment of patients with postoperative enterocutaneous fistulae reflect the heterogeneity of the disease and depend on the patient's condition and the characteristics of the fistulae. For this reason, the use of a prognostic index, which enables such patients to be classified according to their risk of death, could be useful. In this study we propose a prognostic index based on a logistic regression analysis, obtained by using two (APACHE II score and serum albumin concentration) of the eight risk factors that have been retrospectively analysed in a series of 70 patients with postoperative enterocutaneous fistulae treated in our surgical department since 1981. The logistic regression equation indicates that patients with a probability of dying of less than 0.35 have a good prognosis, with a sensitivity of 90 per cent, a specificity of 90 per cent, a negative predictive value of 79 per cent, a positive predictive value of 96 per cent and an accuracy of 90 per cent. The predictive performance of the index has also been evaluated in a group of 17 patients studied prospectively, and this confirms the sensitivity and specificity of the model. This postoperative enterocutaneous fistulae index could be a helpful tool in clinical trials and surgical audit.

Increased production of procoagulant activity (tissue factor) by human peripheral blood monocytes after Intralipid infusion.

Intralipid can produce functional and structural changes in the mononuclear phagocyte system. We have investigated the effect of Intralipid on the capacity of peripheral blood human monocytes to produce procoagulant activity when incubated in short term cultures. Twenty-three patients were studied before and after a single infusion of Intralipid 10%. Procoagulant activity was measured on isolated mononuclear cells after incubation (4 h at 37 degrees C) with and without endotoxin, using a one-stage clotting assay. Mononuclear cells obtained after Intralipid infusion produced significantly increased procoagulant activity as compared to their pre-infusion control samples (p < 0.005). Similar results were obtained when freshly collected whole blood was incubated with and without endotoxin (4 h at 37 degrees C) and procoagulant activity was measured on subsequently isolated mononuclear cells (p < 0.005). In all instances procoagulant activity was identified as tissue factor. Patients in the need of Intralipid are often at increased risk for thromboembolic complications and/or disseminated intravascular coagulation because of malignant disease, surgery or infection and there is evidence that the procoagulant activity of mononuclear phagocytes could play a major role in these processes. Our findings suggest that Intralipid might cause a further accentuation of the thrombotic tendency as a result of increased procoagulant activity.