Prospective multicenter observational trial on the safety and efficacy of LEVORAG® Emulgel in the treatment of acute and chronic anal fissure.

BACKGROUND: Anal fissure (AF) is a common cause of anal pain with a tendency not to heal spontaneously because of ischemia of the anoderm caused by sphincter spasm. Lateral internal sphincterotomy, while very effective, can cause fecal incontinence and chemical sphincterotomy by application of cream may have discouraging side effects and/or low efficacy. The aim of this prospective multicenter study was to evaluate the safety and effectiveness of a new medical treatment based on Emulgel cream, with emollient, soothing and protective agents, on AF healing. METHODS: Consecutive patients with AF treated in nine coloproctology units during 6 months entered the study on topical treatment with Levorag(®) Emulgel (THD S.p.A Correggio (RE), Italy). Before treatment, they had a proctologic examination and pain was measured using a visual analog scale. THD Levorag(®) Emulgel was applied every 12 h for 40 days. Monitoring was scheduled at 10, 20 and 40 days. At time 0 and at the end of treatment, patients underwent anorectal manometry, if possible. RESULTS: Two hundred eighty-four AF patients were recruited (171 acute fissures). Complete healing was achieved in 47.9 % of the cases, an improvement in 31.0 % (global efficacy 78.9 %). In patients with acute fissure, the rate of efficacy was 89.4 % (complete healing: 64.3 %, improvement: 25.1 %), in those with chronic fissure the rate of efficacy was 62.8 % (complete healing: 23 %, improvement: 39.8 %), p < 0.001. Pain and resting anal pressure decreased significantly after treatment. CONCLUSIONS: Treatment with THD Levorag(®) Emulgel proved to be effective for the reepithelization of AF and the reduction of pain in the short term in about 80 % of patients.

Pelvic floor imaging: comparison between magnetic resonance imaging and conventional defecography in studying outlet obstruction syndrome.

PURPOSE: This study prospectively compared the diagnostic capabilities of magnetic resonance (MR) imaging with conventional defecography (CD) in outlet obstruction syndrome. MATERIALS AND METHODS: Nineteen consecutive patients with clinical symptoms of outlet obstruction underwent pelvic MR examination. The MR imaging protocol included static T2-weighted fast spin-echo (FSE) images in the sagittal, axial and coronal planes; dynamic midsagittal T2-weighted single-shot (SS)-FSE and fast imaging employing steady-state acquisition (FIESTA) cine images during contraction, rest, straining and defecation. MR images (including and then excluding the evacuation phase) were compared with CD, which is considered the reference standard. RESULTS: Comparison between CD and MR with evacuation phase (MRWEP) showed no significant differences in sphincter hypotonia, dyssynergia, rectocele or rectal prolapse and significant differences in descending perineum. Comparison between CD and MR without evacuation phase (MRWOEP) showed no significant differences in sphincter hypotonia, dyssynergia or enterocele but significant differences in rectocele, rectal prolapse and descending perineum. Comparison between MRWEP and MRWOEP showed no significant differences in sphincter hypotonia, dyssynergia, enterocele or descending perineum but significant differences in rectocele, rectal prolapse, peritoneocele, cervical cystoptosis and hysteroptosis. CONCLUSIONS: MR imaging provides morphological and functional study of pelvic floor structures and may offer an imaging tool complementary to CD in multicompartment evaluation of the pelvis. An evacuation phase is mandatory.

Hemoperitoneum as severe and unusual complication in the stapler recto-anopexy for hemorrhoidal prolapse. Case report.

We report unusual but severe complication after Longo recto-anopexy for hemorrhoidal prolapse, i.e. large intramural hematoma of the rectum and subsequent hemoperitoneum. We make some assessment about the technique.

[Hyponatremia: etiopathogenetic observations in the personal experiences]. / L'iponatremia : rilievi etiopatogenetici in esperienze personali.

AIM: Hyponatremia, an electrolyte disturbance, can be due to loss of solutes or to an increase of ''free'' water concentration, predominantly caused by excessive antidiuretic hormone (ADH) secretion. When acute, hyponatremia is threatening, because it can cause cell swelling and severe neuromuscular symptoms (central pontine myelinolysis). METHODS: In a sample of 220 subjects with hyponatremia (123 males, 97 females) aged from 47 to 83, hospitalized in the Department of Clinic Medicines and Emergent Pathologies, from 2000 till today, age, serum and urinary sodium concentration, urine specific gravity, signs, symptoms and causes of electrolyte disturbance were evaluated. Student's t-test was applied for parametric spread data, Mann-Whitney Test for no parametric spread data, ANOVA test for statistic comparison between groups. RESULTS: Hyponatremia due to an increase of ''free'' water prevails in respect to hyponatremia due to loss of solutes (55.9% vs 44%). In the first case the prevalent causes are: decompensated hepatic cirrhosis (37.3%), heart failure (31.7%), glucosate solutions at 5% (17.8%) and drugs that can potentially increase ADH secretion (antidepressants, etc.) (13%), especially in elderly people. In the second case chronic diarrhea, vomiting (40%, 32.9%) and diuretic-induced hypernatriuresis (18.5%) prevail. Laboratory results follow the grade of efficient volemia, registering statistically significant differences between the two variants of hyponatremia. CONCLUSION: Different diagnosis and adequate treatment are essential when hyponatremia is acute. Particular attention must be reserved to elderly people with hyponatremia, in which the mechanisms of ''free'' water clearance are inefficient and such hypotonic glucosate solutions as medicines that increase ADH secretion (psychodrugs) must be administered with caution and under clinical control.

Idiopathic myenteric ganglionitis underlying acute 'dramatic' intestinal pseudoobstruction: report of an exceptional case.

Inflammation of the myenteric plexus of the gastrointestinal tract is a very rare pathological condition, with few reports in the medical literature. This pathological condition causes atonic gut motor dysfunction and is principally secondary to other diseases, being reported nearly solely as a paraneoplastic phenomenon in neuroendocrine lung tumors, including small cell carcinomas or neuroblastomas. In addition it can also be associated with disorders of the central nervous system, although it has rarely been described in Chagas disease. It has been named 'idiopathic myenteric ganglionitis' because no apparent causes can be demonstrated. We report the clinicopathologic findings of an exceptional case of a young woman affected by severe chronic constipation suddenly changing into acute intestinal pseudoobstruction with dramatic evolution. Relationships between ganglionitis, idiopathic constipation and acute intestinal pseudoobstruction as well as therapeutic implications are discussed.

Anal GIST in older old patient: a case report.

UNLABELLED: GIST are a group of quite rare neoplastic pathologies. This type of pathology is currently the subject of discussion as for their origin and treatment. It is generally difficult to determine if they are to be considered as a benign or malignant neoplastic disease. We present the case of a patient with recurrence of anal GIST who was examined 8 years after the first treatment. CASE REPORT: C.M., female, 81 years old, came to our Clinic in March 2001 complaining of rectal haemorrhage and abdominal pain in the lower quadrants; she had also suffered from constipation for 1 month. During rectal exploration we found a mass spreading inside the lumen 3 cm from the anal verge. Colonoscopy showed that the tumour, which was 7 x 5 cm in size, was inside the wall with normal mucosa. EUS revealed that the origin was within the muscular layer; therefore we chose transanal excision as surgical treatment. The patient was discharged 5 days after surgery and is alive; she only showed a small local recurrence of disease 30 months after treatment. Histological examination confirmed that the tumour was a GIST This case provides the basis for a discussion about characteristics and the evolution of this group of pathologies.

Hemorrhoidal stapler prolapsectomy vs. Milligan-Morgan hemorrhoidectomy: a long-term randomized trial.

BACKGROUND AND AIMS: The notable success of stapled prolapsectomy in recent years led us to compare this technique with Milligan-Morgan hemorrhoidectomy in terms of the results obtained both in the immediate postoperative period and in the long term. PATIENTS AND METHODS: We performed conventional hemorrhoidectomy on 50 randomly selected patients and operated on a further 50 using the stapler technique. The patients were monitored over the immediate postoperative period (e.g., type of anesthesia, mean duration of operation, mean hospitalization time, analgesic administration, time before returning to work) and over a long-term follow-up period of 48 months (later complications such as prolapse relapse, bleeding, stenosis, incontinence). RESULTS: The stapled group experienced significantly less pain (mean number of analgesic tablets 2.60 vs. 15.9) and returned to normal activity sooner (8.04 vs. 16.9 days), as reported by other authors. In the long-term follow-up at 48 months, stapled hemorrhoidectomy was found to control prolapse, discharge, and bleeding, with no stenosis or significant incontinence, in 94% of cases. CONCLUSION: Our conclusions confirm the excellent advantages of stapled hemorrhoidectomy which allows the rapid recovery of patients and also promises the complete resolution of hemorrhoidal prolapse in the long term.

[Clinical approach in hypertensive elderly patients]. / Considerazioni sull'approccio clinico di pazienti anziani ipertesi.

Hypertension in the elderly represents a cardiovascular risk factor which increases due to ageing and to the raise of blood pressure (BP) values. The occurrence of hypertension depends on an interaction between genes and environment. An available antihypertensive therapy causes a reduction in the incidence of cardiovascular events. An antihypertensive therapy in the elderly must take into account: in these subjects BP might be spontaneously lower over 30 mmHg in 24 hours; people normally have a postprandial BP reduction; sudden raises or falls of pressure cause cerebral hypoperfusion; some adverse vents of hypertensive drugs worsen their quality of life, not reducing myocardial hypertrophy; possible electrolytic troubles might worsen a congestive heart failure; drastic diets cause a raise in the incidence of colorectal tumours; a high heart rate increases the risk of sudden death; a chronic NSAID intake might cause or aggravate a hypertensive state; a reduction of natrium chlorure and lipides in the diet might cause a BP fall. In short, the BP reduction should be gradual in the hypertensive elderly in order to avoid the occurrence of cardiovascular events, diets should be balanced, rich in fibres and vitamins to avoid colorectal tumours. Besides, NSAID must be used by these patients for a short time and all therapeutic interventions should improve their quality of life.

[The surgical therapy of renal carcinomas. The prognostic factors and long-term results]. / Terapia chirurgica dei carcinomi renali. Fattori prognostici e risultati a distanza.

BACKGROUND: Image diagnosis of kidney neoplasms allows good preoperative staging using the TNM system, but surgical management cannot be based on these data because a tumour apparently confined to the kidney may have produced metastasis in extraregional lymph nodes. METHODS: Thirty-three patients with renal carcinoma were observed over a seven-year period. Preoperative staging using the TNM system was performed and then compared with postoperative staging. Radical nephrectomy and regional lymphadenectomy were performed in all patients. Extensive lymphadenectomy was undertaken in 10 cases presenting neoplasms larger than 10 cm. At the preoperative assessment, 20 patients were stage T2, 13 stage T3, for factor N six were N1, two M1; postoperative staging confirmed T2 in 15 cases, whereas five T2 became T3. After postoperative staging, the N1 patients increased from 6 to 13. Fifteen patients were at Robson's stage II, four at stage IIA, twelve IIIB and two stage IV. RESULTS: The 5-year survival rate was 63.2%. CONCLUSIONS: The authors conclude that from an analysis of the correlation between tumour size and lymph node metastasis it can be seen that low T values do not represent grounds for conservative treatment.

[Severe myogenic pain in an unfit subject after intensive and prolonged abdominal muscle exercise]. / Marcata sofferenza miogena in un soggetto non allenato dopo intenso e prolungato esercizio fisico di flesso-estensione dei muscoli addominali.

The authors report the case of an unfit patient who, following intensive and prolonged physical exercise involving the abdominal muscles, presented a massive and diffuse subcutaneous edema (abdomen, scrotum, chest and face) together with abdominal and thoracic pain which increased in response to finger pressure. In addition, this was accompanied by a marked increase in CK, CK-MB and LDH, and TGO and TGP. Chest or heart pathologies were excluded by monitoring ECG and other clinical parameters, like heart rate and blood pressure, and by performing a chest X-ray. Muscular ultrasonography confirmed the massive subcutaneous edema and abdominal MR showed a slight edema in the suprasacral region, as well as confirming the subcutaneous edema. Hematological data gradually reduced and returned to normal after a week. Edema and pain also regressed gradually: the former finally disappeared after one week and the latter after five days. The authors conclude that clinical and laboratory findings were particularly severe because the subject was unfit and subcutaneous edema was larger than the free liquid in the abdominal cavity because the latter was absorbed by the peritoneum which acted as a dialysing membrane.

Monitoring carcinoembryonic antigen in colorectal cancer: is it still useful?

The results of a study conducted to determine the usefulness of carcinoembryonic antigen (CEA) monitoring in the follow-up of patients with resected colorectal cancer are reported herein. The subjects of this study were 125 patients in whom CEA had been determined preoperatively and 239 patients in whom CEA had been monitored postoperatively. The results revealed increased preoperative CEA in only 24% of the subjects, and that this increment was correlated with subsequent more advanced tumor stage and a higher recurrence rate (P < 0.01). The postoperative CEA level exceeded the threshold in 71% of the patients affected by recurrence, 94.4% of whom developed liver metastases and 50%, nonhepatic recurrence. This marker showed elevated sensitivity for liver metastases (99%), whereas the sensitivity was lower for nonhepatic recurrence of the disease (94%). Thus, we concluded that CEA monitoring can be useful for preoperative colorectal tumor grading, even if its validity in the early diagnosis of recurrence is problematic, especially in terms of radical repeated surgery and survival.

Usefulness of microsurgery in the training of the general surgeon.

It is a common opinion that general surgery is the first step for whoever approaches a surgical discipline, and that whoever practices training in general surgery should learn the rudiments of each surgical branch. The role of microsurgery in the training of the general surgeon has not been well-established. Clinical applications of microsurgery in general surgery are few and are rarely required, and have been connected strictly to restricted indications. However, we think that microsurgery could be very useful to the general surgeon because it allows the execution of experimental research on rats, the only possibility permitted by law. In these studies the microsurgeon can perform many times and in a short time the same surgical operation, thus improving his skill, and easily getting familiarity with surgical instruments and sutures.

[Therapeutic strategy in thymomas]. / Strategia terapeutica nei timomi.

Between July 1989 to February 1994 eight patients with thymoma were operated in the First surgical Clinic of University of Catania; in seven the neoplasia was associated with myasthenia gravis, the severity of which was evaluated according to the Osserman's classification. The surgical treatment has been: total thymectomy in four patients, in two total and partial resection was carried out respectively, and in two a macrobiopsy was performed. The postoperative staging was carried out according to Masaoka. The neoadjuvant chemotherapy and postoperative radiation therapy have been analyzed. The authors concluded that a rigorous anatomo-surgical and histopathological classification is the best way for the right use of postoperative adjuvant therapies to reduce the incidence of local and distant recurrence of these tumors.

[Morpho-functional evaluation of subjects who had undergone surgery for ano-rectal malformations using the Peña technique]. / Valutazione morfo-funzionale dei soggetti operati per malformazione ano-rettale secondo la tecnica di Peña.

The approach to patients with Ano-Rectal Malformations (ARM) has undergone a substantial change in these last years due to the evolution of the studies of the anatomy and physiology carried out by Peña and de Vries. The authors report their experience on 15 patients and analyse the clinical and instrumental results according to the quality of life of the patients. There are different clinical criteria for the postoperative evaluation of these patients. The authors considered the Kelly, Kiesewetter, Peña and Holdschneider methods and compared the different values obtained. Moreover, they analysed the results of anorectal manometry performed in 10 patients and their correlations with clinical scores. The authors assert that the TC or NMR tests are unnecessary for these patients, since these methods demonstrate a correct position of the rectum within the muscular structure, but do not allow a correct evaluation of the quality of life of these patients. The clinical results obtained by the authors are satisfying; however, the number of patients is limited and the follow-up is relatively short.

Favourable anatomical variation for the resection of a Klatskin tumour.

The liver and the biliary tract are rich in anatomical variations, knowledge of which is important for the surgeon. A case of an anatomical variation is reported, which allowed easy and oncologically correct resection of a Klatskin tumour. The variation consisted of abnormally long right and left extrahepatic ducts and an abnormal distal bifurcation, with a cystic duct joining the distal end of the right duct. A favourable modification of surgical strategy could be obtained by an oncologically correct resection of a Klatskin tumour avoiding a liver resection and also allowing easy reconstruction. Complete biliary exposure was necessary to reveal the rare, pre-operatively unrecognized, but favourable situation. In the absence of clear contraindications extended biliary dissection is to be recommended to avoid errors in the evaluation of the resectability of hilar biliary cancers.

Retroperitoneal abscesses--rare causes and atypical manifestations: report of two cases.

Retroperitoneal space abscesses are a life-threatening illness which is difficult to diagnose and treat because of both their rarity and insidious clinical manifestations. The insidious development of this illness is a challenge for all medical and surgical subspecialists. The discovery of the real source of the infection is very important but not always possible, and knowledge of the anatomy and borders of the retroperitoneal space is helpful in understanding all such atypical cases and for establishing a definitive treatment. Two cases are reported that are both characterized by rare causes, uncommon development, and atypical manifestation. The normally undefined inferior borders of some parts of the retroperitoneal space or previous retroperitoneal surgery could have been the cause of the abnormal and misleading development of the abscesses. Chronically infected organs can be the true origin of this abscess, and their discovery in a nonemergency situation is mandatory for complete surgical treatment. These cases show that knowledge of the anatomy of the retroperitoneal space is important to establish the suspicion of an abscess, to understand its manifestations, which are sometimes caused by a rare pathophysiology, and to initiate appropriate treatment.

[The diagnostic significance of the small bowel enema in lesions of the small intestine requiring surgery]. / Importanza diagnostica del clisma del tenue nelle lesioni di interesse chirurgico del piccolo intestino.

Given its anatomical location the small intestine is the section of the digestive tract most inaccessible to objective clinical and instrumental examination. For this reason, traditional investigation methods provide inadequate data. In the barium meal X-ray, images are superimposed and the barium excessively fragmented due to the tortuosity and length of the intestinal loop. Access problems limit the value of endoscopy. The indications to angiography are fairly restrictive. Ultrasound and CT scans provide no conclusive evidence in this area. The so-called Small Bowel Enema technique based on the direct infusion of an opaque contrast medium after duodenal intubation remains the only way to obtain images with a satisfactory diagnostic value and should be the method of choice in examinations of the small intestine. Introduced in the twenties, the value of the technique was long questioned, mainly because it was difficult to perform correctly and it is only quite recently that several decisive technological innovations have made it highly reliable. The present paper describes its use on a series of patients with suspected pathologies of the small intestine requiring surgical treatment. The aim is to specify the correct indications to this technique as well as its limitations with a view to promoting its appropriate use in routine practice. MATERIALS AND METHODS. The study covers 42 small bowel enemas performed on 29 male and 13 female patients aged 12-85 years. Indications to the enema included chronic abdominal pain in 28.5%, chronic diarrhea in 21.4%, pain+diarrhea in 14%, subocclusion in 16.5%, faecal blood in 11.9%, abdominal pain+diarrhea+intestinal haemorrhage in 4.7%, anaemia in 2.4%. We adopted the Sellink technique involving intubation with a French 14 Bilbao-Dotter probe and the infusion of 200-350 cc barium sulphate in a 90%-70% P/V concentration at a speed of 100 ml/min, followed by the infusion of 1000-1500 cc 0.5-1% methylcellulose in a 50-50 mixture with water for double contrast purposes. Mean duration of procedure 35-40 mins. RESULTS. We found lesions of the small intestine in 18 cases or 45% (true positives) and no alterations in 18 or 42.8% (true negatives). In 3 cases (7%) the examination was inconclusive. One false positive and one false negative complete the series, making a diagnostic accuracy of 89.1%. In 23.8% of the total series the diagnosis of Crohn's disease was confirmed; cancerous lesions were found in 11.9% and adhesions following earlier surgery in 9.7%. Surgery confirmed this diagnosis in 10 cases (5 tumours, 3 stenoses caused by adhesion fragments, 2 Crohn's disease) and disproved it in one case. Biopsy was used, for objective confirmation in 5 cases (2 Crohn's disease, 3 negatives). In the other cases reliance was placed on clinical course and the patients' response to treatment. DISCUSSION AND CONCLUSIONS. Examination of our results reveals that in most clinical cases the small bowel enema was used to confirm suspected Crohn's disease (31 cases out of 42) and with a very high degree of diagnostic accuracy (96.7%). In line with data in the literature we decided to base the indication to this examination on certain primary symptoms such as chronic abdominal pain, diarrhea, blood in the faeces, whether in isolation or in combination. On this rather general basis the diagnosis of Crohn's disease concerned only 23.8% of the cases studied, an incidence that rose dramatically in the few cases in which the indications were made more specific. We therefore conclude that the adoption of more restrictive criteria will improve the cost-benefit ratio for this test. Another major pathology in which small bowel enema possesses a high diagnostic value is partial obstruction of the small intestine.(ABSTRACT TRUNCATED AT 400 WORDS)

[Role of gonadal phlebography in the diagnosis of cryptorchidism]. / Ruolo della flebografia gonadica nella diagnostica del criptorchidismo.

The authors describe the diagnostic procedures for testicular localization in patients with non palpable undescended testes. They consider the procedures as invasive and non invasive. The first procedures include ultrasonography, C.T. and N.M.R., the second ones laparoscopy, selective arteriography and venography of the spermatic vessels. Anatomy of spermatic venous system and catheterization techniques are described. Conclusions are that when non invasive procedures fail to localize the testis, gonadal venography is the procedure of choice for the correct diagnosis. Preoperative testicular localization often reduces the extent of surgical exploration and the anesthesia time. These patients have to undergo surgical treatment also when gonadal venography shows a blinding end vein in the inguinal canal, because of the intra-abdominal testis possible degeneration.

[Motor disorders of the esophagus in gastro-esophageal reflux disease]. / I disordini motori dell'esofago nella malattia da reflusso gastro-esofageo.

The Authors report their experience in the study of oesophageal motor abnormalities in patients with gastroesophageal reflux disease. By an electromanometric test in 50 subjects (20 healthy volunteers and 30 patients with oesophagitis), they evaluated the results concluding that: 1) LES low pressure is correlated significantly with oesophagitis; 2) oesophageal peristaltic dysfunction could be the effect of oesophagitis rather than its cause.