Recurrent gallstone ileus: case report and literature review.

The gallstone ileus is a rare complication of cholelithiasis and it represents the 1-4% of small intestinal mechanical obstruction. Gallstone is generally wedged in the terminal ileum, even if unusual locations have been described. The literature reports a very high morbidity and mortality, often because misdiagnosis or delayed diagnosis. There is no unique opinion in literature about the choice between one-stage and two-stage surgery. We report a clinical case that summarizes the diagnostic and therapeutic difficulties of gallstone ileus.

[Factors associated with ileal-pouch related fistulas in 100 consecutives patients who underwent restorative proctocolectomy]. / Fattori associati alla comparsa delle fistole pouch-correlate in uno studio su 100 pazienti sottoposti a pouch ileo-anale.

OBJECTIVE: The pouch-related fistulas range in literature from 2% to 16% and they can be cause of failure of the intervention of restorative proctocolectomy. Aim of this study was to examine factors associated with theirs development and to identify theirs possible etiology and pathogenesis. MATERIALS AND METHODS: Retrospective study focusing on 100 consecutive patients who underwent restorative proctocolectomy with pouch-anal anastomosis (IPAA). Patients with fistula and patients without fistula have been identified and the fistula type, the time from surgery and the site relative to IPAA have been recorded. Patients' demographics, co-morbidity or related medical history, clinical indication for treatment, surgical method, histological diagnosis, length of follow-up, early and late postoperative complications have been reviewed, and data collected have been compared among the two groups through univariate analysis. RESULTS: The overall incidence of fistulas was of 10% (10 cases); 8 cases had pouch-vaginal fistulas, involving the distal tract of the vagina, and associated with pouch-perineal fistulas in 2 cases; 1 case had pouch-vulval fistula; 1 case had a complex pouch-perineal fistula. Three fistulas were precocious, all associated with an IPAA leak; 2 of these cases also had pelvic sepsis while the third had delayed diagnosis of Crohn’s disease. Seven fistulas had a late development. Four fistulas occurred at the level of the IPAA; 5 fistulas were located below the IPAA, and 1 fistula originated above and below the IPAA. When the two groups of patients were compared we found that there was an higher percentage of perineal or anal disease (40.0% vs 2.2%; p <0.001), of extraintestinal manifestations of inflammatory bowel disease (IBD) (40.0% vs 3.3%, p <0.001), and of leak of the IPAA (40.0% vs 11.1%; p <0.05) in the group with fistula vs the group without fistula. CONCLUSIONS: A direct link with the leak of the IPAA appears in all the early fistulas, while the cryptoglandular infection was suggested as a possible cause of the late fistulas located below the IPAA; the association with the extraintestinal manifestations of IBD could show a correlation between the fistulas and an higher specific activity of the underlying chronic inflammatory disease.

Palliative treatment for malignant jaundice: endoscopic vs surgical approach.

In this retrospective, comparative study a total of 107 patients, presenting with malignant inoperable strictures of common bile duct, due to a pancreatico-biliary malignancy, underwent palliative treatments. In a group, consisting of 82 patients (76.64%), endoscopic stenting procedures were performed; polyethylene stents or self-expanding metal stents were applied in 37 and 45 patients, respectively. The prerequisites for a successful endoscopic stenting were a) accuracy of diagnosis and b) exclusion of patients presenting with tumors potentially treatable by a curative resection. In the other group, consisting of 25 patients (23.36%), biliary-enteric bypass procedures were performed. Endoscopic treatment was successful in 97.5% of the cases (80/82); complication rate was 7.3% (6 patients on 82), and mortality rate was 3.6% (3 patients on 82). Median hospital stay was 13.4 and 7.3 days in patients treated with plastic stents and metallic stents, respectively. Bypass surgery was successful in 99% of the cases (24/25); complication rate was 24% (6 patients on 25), and mortality rate was 16% (4 patients on 25). Median hospital stay was 26 days. For the patients in whom a curative resection could not be performed, both the above mentioned methods resulted in a high rate of immediate technical and therapeutic success. However, the surgical approach showed a significantly higher rate in procedure-related mortality and morbidity; in addition, the hospital stay lasted longer in surgically treated patients. The patients who are definitely unsuitable for curative resection are better managed by positioning a stent. The use of metal stents should be preferred in those less serious patients who may supposedly survive longer.

Sentinel node role in breast cancer surgery.

Radical surgery of breast cancer includes lymphadenectomy of axilla as well as the dissection of the neoplastic tissue. However recently many works have raised doubts on the opportunity of performing routinary axillary dissection, which elevates morbidity risk, in absence of axillary metastases. However, unfortunately, information on axillary lymph node pathology, is not available with any other technique excluding complete dissection and istopathological examination. Sentinel node technique is a new methodology that consents evaluation of lymph node status in the operating theatre. It allows the surgeon to judge on the opportunity of carrying out the lymphadenectomy or not.

Surgical indications and techniques in the treatment of chronic pancreatitis.

Forty-six patients operated on for chronic pancreatitis are reported. 3 (6.4%) underwent splanchnicectomy, 29 (59.2%) Roux-en-Y side-to-side pancreaticojejunostomy, 17 (34.6%) resective procedures (8 left hemipancreatectomy, 5 subtotal pancreatectomy, 3 pancreaticoduodenectomy, 1 total pancreatectomy). Overall postoperative morbidity was 13%: 29.4% after excisional surgery and 3.4% after drainage procedures. One patient treated by subtotal pancreatectomy died because of a hepatorenal syndrome. All the 3 patients treated by splanchnicectomy required resection within two years. The best results were obtained by pancreaticojejunostomy. Drainage procedures represent the operations of choice for chronic pancreatitis as long as correct indications exist. Splanchnicectomy has been discarded as a mean of pain relief because of pain recurrence with time.

[Value of computerized tomography in the early detection of pelvic recurrences in patients subjected to resection of rectal cancer]. / Valore della tomografia computerizzata nell'accertamento precoce di recidive pelviche in pazienti sottoposti ad intervento di resezione per carcinoma del retto.

Forty eight patients surgically treated for carcinoma of the rectum were by computed tomography (CT) during routine follow up to test the value if this procedure in the early diagnosis of pelvic recurrences. We used a protocol which schedules controls at different intervals for Dukes A e B and for Dukes C patients; CT showed pelvic recurrences in 13.3% of the Dukes A e B and in 50% of Dukes C cases. CT seems to be the most reliable presently available test in detecting early extraluminal recurrence after radical resection for rectal cancer.