Gastrointestinal obstruction caused by solidification and coagulation of enteral nutrition: pathogenetic mechanisms and potential risk factors.

Enteral nutrition (EN) is preferred in order to provide nutrition and reduce catabolism in critically ill patients. Recent studies suggest that the use of EN is successful and complications are rare. However, an underestimated mechanical complication of tube feedings seen in critically ill patients is the coagulation and solidification of the EN causing gastrointestinal obstruction. This report describes two clinical cases (1.23% of all cases seen at our clinic) of obstruction and perforation of the small bowel secondary to the solidification of EN. The understanding and early recognition of this potential complication are essential for the prevention and successful treatment of this condition.

Novel endoscopic management for pancreatic pseudocyst with fistula to the common bile duct.

Pancreatic pseudocyst formation is a well-known complication of pancreatitis. It represents about 75% of the cystic lesions of the pancreas and might be located within or surrounding the pancreatic tissue. Sixty percent of the occurrences resolve spontaneously and only persistent, symptomatic or complicated cysts need to be treated. Complications include infection, hemorrhage, gastric outlet obstruction, splenic infarction and rupture. The formation of fistulas to other viscera is rare and most commonly occurs within the stomach, duodenum or colon. We report a case of a patient with a pancreatic pseudocyst in communication with the common bile duct. There have been only few cases reported in the literature. We successfully managed our case by performing an endoscopic ultrasound-guided drainage of the pancreatic collection and a contemporaneous stenting of the common bile duct. Performed independently, both drainages are effective, safe and well-coded and the expertise on these procedures is widespread. By our knowledge this therapeutic approach was never reported in literature but we retain this is the most correct treatment for this very rare condition.

Laparoscopic cyst fenestration in the treatment of polycystic liver disease.

INTRODUCTION: The PLD, included in the group of malformative lesions of ductal plate, is characterized by progressive development of multiple parenchymal cysts. Different surgical treatments have been proposed for symptomatic patients with PLD: percutaneus aspiration, fenestration, hepatic resection and liver transplantation. The aim of this report is to outline the treatment of polycystic liver disease with laparoscopic fenestration. MATERIALS AND METHODS: Of thirteen patients with PLD, in all cases associated with polycystic kidney disease, 7 patients underwent to laparoscopic treatment of cysts fenestration, and 6, asymptomatic and not amenable to surgical treatment, underwent to clinical follow-up. Of the 7 patients, 5 have symptoms related to "effect mass" 1-2-3 of hepatic cysts while in the 2 asymptomatics the fenestration of the cysts was performed during the procedure of laparoscopic cholecystectomy for cholelithiasis. DISCUSSION: The best indication for laparoscopic fenestration are those cases of PLD characterized by a relatively limited number of large cysts, preferably situated in the anterior segments of the liver and in the left lobe; in this patients, laparoscopic fenestration reduces significantly the volume of the liver and relieves symptoms. The laparoscopic fenestration of hepatic cyst, in carefully selected patients, is an effective technique in terms of morbidity, mortality, conversion rate and recurrence rates; while in patients with cyst diffuse in liver parenchyma is indicated the hepatic resection or liver transplantation. The optimal surgical approach is still evolving, the type of approach is related to extent and distribution of the cysts, and vascular anatomy of normal segment of the liver. KEY WORDS: Laparoscopic fenestration, Policystic liver.

[Post-operative analgesia in case of ano-rectal diseases]. / L'analgesia post-operatoria nel trattamento delle patologie ano-rettali.

BACKGROUND: The aim of the study was that to evaluate the post-operative pain in case of ano-rectal diseases wether treated by ketorolac, or buprenorphine or tramadol. MATERIALS AND METHODS: The intensity of post-operative pain was evaluated in 60 patients with hemorrhoidal diseases, fistulae, abscesses and anal neoplasms, divided into three homogenous groups and treated with intramuscular ketorolac (Group I), transdermal buprenorphine (Group II) and tramadol in elastomeric pump (Group III). RESULTS: The average index of the visual analogue scale, as mean to evaluate the intensity of the post-operative pain, was 1,85 in the first group, 1,20 in the second one and 1,40 in the third group. DISCUSSION: In patients treated with transdermal buprenorphine or with tramadol in elastomeric pump there has been a more quick psycho-physical recovery than in those treated with ketorolac; the management of elastomeric pump represents however for patients cause of concern while the transdermal system is a kind of rational and comfortable way of treatment of the pain, with the advantage of being non-invasive. CONCLUSIONS: Better compliance and lower operating costs have given the preference to the use of transdermal buprenorphine for the treatment of diseases of the post-operative pain in the diseases of the anal canal.

[Skin neuroendocrine carcinoma metastasis: a case report]. / Metastasi da carcinoma neuroendocrino della cute. Caso clinico.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare and aggressive skin tumour with a highly malignant nature whose appropriate treatment is still debated. The Authors report a case of cutaneous metastasis from neuroendocrine carcinoma and analyse new diagnostic and therapeutic options of neoplasms that occurs in sun-exposed areas. METHODS: The authors present the clinical, immunocytochemical characteristic of primary and secondary skin localization of a neuroendocrine tumor that affected a woman. RESULTS: Histological and immunocytochemical analysis demonstrated that the secondary cutaneous localization appeared to be compared to the primary tumour. CONCLUSIONS: The case confirm the high incidence of regional metastasis; a wide surgical excision of tumor and regional lymphadenectomy is therefore recommended for primary treatment of MCC; the radiation treatment minimized the local recidives with long time survival.