Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

Complete substitution of the left ureter with vermicular appendix during hemicolectomy for cancer in an adult patient.

We demonstrated that a complete left ureteral substitution with appendix is a feasible and safe technique. To our knowledge, this is the first case of a successful complete substitution of the left ureter with vermicular appendix in an adult patient reported in the literature.

Long-Term Functional Outcome after Internal Delorme's Procedure for Obstructed Defecation Syndrome, and the Role of Postoperative Rehabilitation.

PURPOSE: To evaluate long-term functional outcomes of Internal Delorme's Procedure (IDP) in patients refractory to conservative treatment for Obstructed Defecation Syndrome (ODS), and to compare those who received postoperative rehabilitation with those who did not. MATERIALS AND METHODS: All patients with ODS refractory to nonoperative therapy were identified across three regional pelvic floor referral hospitals, and IDP was performed. Postoperatively selected patients received biofeedback therapy. Functional outcomes were established using the Cleveland Clinic Constipation (CCC) score and obstructed defecation score (OD score) preoperatively at 12 months and at the last available follow-up. Patient satisfaction was assessed with a visual analogue score. RESULTS: From October 2006 to September 2013, IDP was performed in 170 patients: 77 received postoperative biofeedback and 93 did not. Mean follow-up was 6.3 years (range 1-8 years). CCC and OD scores improved significantly in both groups after 12 months and at the last follow-up (p > 0.05). When comparing two groups while there was no significant difference between CCC and OD scores at 12 months, score was significantly better in the group that received rehabilitation at the last follow-up (p = 0.001). Patient satisfaction was higher in the rehabilitation group (67%) compared with those without rehabilitation (55%). Clinical recurrence was recorded in nine patients who did not have postoperative rehabilitation. CONCLUSIONS: It has been demonstrated that IDP is associated with good long-term functional outcomes. Patients receiving rehabilitation had a better long-term follow-up, a higher overall satisfaction, and lower recurrence rate when compared with the patients who did not receive postoperative rehabilitation.

A Particular Use of Endobag®: Extraction of Rectal Foreign Bodies.

INTRODUCTION: The incidence of foreign bodies (FBs) in the rectum has recently increased. FB removal by the transanal way or by colonoscopy is generally feasible and only in few cases surgery is strictly necessary. Due to FB dimensions or rectum and colon anatomy, sometimes it may represent a challenge. MATERIALS AND METHODS: Two cases of FB inserted in the rectum were treated in our institute. They underwent surgery using Endobag, a laparoscopic surgical device. The device was inserted through the anus in order to catch and remove the FB. RESULTS: Both the procedures were easily performed, without any complication. CONCLUSIONS: The use of Endobag seems to be a good and effective way to remove FB from rectum.

Postsplenectomy recurrence of idiopathic thrombocitopenic purpura: role of laparoscopic splenectomy in the treatment of accessory spleen.

AIM: Idiopatic thrombocytopenic purpura (ITP) is the most common indication for splenectomy. The failure rate of surgery is about 8% and the failure rate after splenectomy is approximately 28% for all patients. When the presence of an accessory spleen is diagnosed, splenectomy is recommended. Laparoscopic approach is considered the first choice. PATIENTS AND METHODS: At our Department, between July and November 2011 two patients underwent laparoscopic accessory splenectomy for recurrence of ITP. Both patients had a previously laparoscopic splenectomy. Preoperative Magnetic Resonance (MR) was performed in both the cases revealing the presence of an accessory spleen. RESULTS: The operative time was 105 and 100 minutes respectively. No perioperative complications occured. Hospital stay was four days in both cases. The first patient had a disease free period of two months; the second one of one month. Both patients restarted immunosuppressive therapy. CONCLUSIONS: The relapse of thrombocytopenia post-splenectomy can be associated with the presence of an accessory spleen. The laparoscopic accessory splenectomy should be considered the first choice approach. Surgical accessory splenectomy allows a transitory remission of the disease.

The dilemma of pneumatosis intestinalis with pneumoperitoneum: nonoperative or surgical management-analysis of a case.

Pneumatosis intestinalis (PI) is an uncommon condition and can be associated with a wide spectrum of diseases, ranging from life-threatening to innocuous conditions. We report the case of a 46-year-old women coming to our attention for an acute abdominal pain, nausea, vomiting, constipation, and increased inflammatory marks, with a CT showing pneumoperitoneum and pneumatosis intestinalis. The previous diagnosis was advanced neoplasia of unknown origin. Despite the surgical intervention, which excluded an ischemic colitis, the patient died in the early postoperative period. The postmortem diagnosis was carcinoma of thymus gland, and the presence of pneumatosis was put down to metastasis nodes in the pulmonary parenchima. This case demonstrates the wide spectrum of presentation of pneumatosis intestinalis, the importance of a careful radiologic evaluation beside the clinical history, since the identification of correct pathogenesis and treatment can be very difficult.

Double PPH technique for hemorrhoidal prolapse: a multicentric, prospective, and nonrandomized trial.

INTRODUCTION: Longo's technique (or PPH technique) is well known worldwide. Meta-analysis suggests that the failure due to persistence or recurrence is close to 7.7%. One of the reasons for the recurrence is the treatment of the advanced hemorrhoidal prolapse with a single stapling device, which is not enough to resect the appropriate amount of prolapse. MATERIALS AND METHODS: We describe the application of "Double PPH Technique" (D-PPH) to treat large hemorrhoidal prolapses. We performed a multicentric, prospective, and nonrandomized trial from July 2008 to July 2009, wherein 2 groups of patients with prolapse and hemorrhoids were treated with a single PPH or a D-PPH. Results were compared. The primary outcome was evaluation of safety and efficacy of the D-PPH procedure in selected patients with large hemorrhoidal prolapse. RESULTS: In all, 281 consecutive patients suffering from hemorrhoidal prolapse underwent surgery, of whom 74 were assigned intraoperatively to D-PPH, whereas 207 underwent single PPH. Postoperative complications were 5% in both groups (P = .32), in particular: postoperative major bleeding 3.0% in PPH versus 4.1% D-PPH (P = .59); pain 37.9 % PPH versus 27.3% D-PPH (mean visual analog scale [VAS] = 2.5 vs 2.9, respectively; P = .72); and fecal urgency 2.1% PPH versus 5.7% D-PPH (P = .8). Persistence of hemorrhoidal prolapse at 12-month follow-up was 3.7% in the PPH group versus 5.9% in the D-PPH group (P = .5). CONCLUSIONS: Our data support the hypothesis that an accurate intraoperative patient selection for single (PPH) or double (D-PPH) stapled technique will lower in a significant way the incidence of recurrence after Longo's procedure for hemorrhoidal prolapse.

Anal avulsion caused by abdominal crush injury.

We report the case of a pelvic and lower abdomen crushing trauma in 37-year-old male patient. The patient had an open lumbar wound, laceration of the psoas muscle, pelvic fracture, a ruptured urogenital diaphragm, and extensive urogenital lacerations. An emergency laparotomy was performed with debridment, urethral reconstruction, and osteosynthesis of the pubic bone. The mobilization of the patient revealed a deep gap, about 8 × 8 cm, in the perineum, with the anus and rectum displaced from their original site. Anal reimplantation was performed, suturing the median raphe, inserting two pelvic drainage tubes, and fashioning a loop transverse colostomy. Closed rectal traumas account for only 4-11% of all rectal traumas. Crushing of the pelvis causes a sudden reduction in its anteroposterior diameter and a corresponding increase in its latero-lateral diameter, together with an abrupt rise in intra-abdominal pressure. The anus is pushed out of the perineal plane due to the divarication of the levator muscles. As suggested in the literature, the standard treatment is wound debridement with immediate or deferred repair, fashioning a diversion colostomy, and repair of the rectum, wherever possible.

[Surgical treatment of extraoesophageal symptoms of GERD. Critical points in the diagnostic-therapeutic pathway]. / Trattamento chirurgico dei sintomi extraesofagei da MRGE. Punti critici nel percorso diagnostico-terapeutico.

Patients with GERD and atypical symptoms represent a particular category with a less clear definition of the physiopatological mechanisms and thereby need a precise attention toward the indication to surgery. The less good response to surgery therefore requires a careful evaluation and selection of patients with atypical symptoms.

Graft vessel wall pathology in a case of hepatic artery pseudo-aneurysm in a liver transplant recipient.

Pseudo-aneurysms (PAs) of the hepatic artery are rare complications of liver transplantation, which are characterized by a high mortality rate. The majority occur within the first 2 months after orthotopic liver transplantation. They become clinically manifest with sudden hypotension, gastrointestinal bleeding, and abnormal liver function test results. Early diagnosis and treatment are essential to prevent life-threatening hemorrhage. Conventional treatment consists of surgical resection and vascular reconstruction, but a feasible treatment option involves an angiographic approach with the positioning of a stent or transarterial coil embolization followed by revascularization. We report a case of posttransplantation hepatic artery PA (HA-PA) with bleeding into the duodenum, diagnosed using abdominal computed tomography (CT). Arterial kinking prevented a covered stent graft from being inserted successfully using X-ray angiography, so the patient underwent emergency surgery in an attempt to exclude the PA and revascularize the organ via an aorto-hepatic bypass with an iliac vascular graft obtained from the donor. The surgical procedure failed due to progressive macroscopic dissection of the HA wall up to the bifurcation. The patient underwent retransplantation but died 25 days later due to multiple-organ failure. Histopathology of the first liver graft confirmed arterial graft dissection and pathological changes in the donor HA wall.

Infliximab in Crohn's disease: a look at the (not so distant) future.

Although infliximab has brought about a major advance in the treatment of Crohn's disease (CD), several questions remain unanswered. In particular, there is no consensus regarding the best timing to use it in the ideal therapeutic algorithm. Another controversial issue is whether this medication should be given or not for life once proven effective in the individual patient. Therapy with infliximab has also been associated to the development of intestinal strictures in CD: hence, some authors have discouraged its use in their presence. Finally, given its powerful antiinflammatory action, infliximab could in theory be effective in preventing postsurgical recurrence of CD, an as yet almost inescapable consequence of "curative" surgery. This review will focus on and discuss the relevant recent literature related to these issues with special regard to the efficacy and safety of infliximab in the presence of intestinal strictures and the potential role of this medication in preventing recurrence after surgery.

Analysis of clinical outcomes and prognostic factors of neoadjuvant chemoradiotherapy combined with surgery: intraperitoneal versus extraperitoneal rectal cancer.

Neoadjuvant chemoradiotherapy (CRT) is a widely purposed and performed treatment for rectal cancer. Downstaging effects possibly enhance the rate of curative surgery and may enable sphincter preservation in low-lying tumours. The current study examines the clinical outcomes in patients enrolled in a neoadjuvant CRT-surgery protocol for rectal cancer, distinguishing between intraperitoneal and extraperitoneal cancer. From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were enrolled in a single-centre, not randomized study based on 5-week sessions of radiotherapy associated with a 30-day protracted venous 5-FU infusion followed by surgical resection. The study population was divided into two groups according to the localization of the tumour: 18 intraperitoneal and 40 extraperitoneal (EPt). Fifty-eight patients were treated with neoadjuvant CRT and surgery. Overall mortality rate was 25.9%, no deaths were recorded during hospitalization; 10 patients (all EPt) died because of recurrence. Significant differences in disease-free survival and overall survival rates were found between intraperitoneal vs. extraperitoneal tumours (P = 0.006), both intraperitoneal vs. extraperitoneal tumours N(0) (P = 0.04 and P < 0.05) and intraperitoneal vs. extraperitoneal tumours N(+) (P < 0.05). We diagnosed all local recurrence and liver metastasis in extraperitoneal tumours (t = 0.02 and t = 0.04), and only one case of lung metastasis arose from intraperitoneal cancer. Extraperitoneal tumours could be more aggressive than intraperitoneal ones, spreading more precociously, and/or less responsive to the neoadjuvant CRT because of their localization rather than biological differences. Aside from lymph node status, the location of the tumour with respect to the peritoneum border, is also a prognostic factor of survival in rectal cancer treated by neoadjuvant CRT and surgery.

Second degree haemorrhoids: patient's satisfaction, immediate and long-term results of rubber band ligation treatment.

AIM: Rubber band ligation (RBL) is a widely performed and well established treatment for second degree haemorrhoids. The aim of our prospective study was to assess the satisfaction of patients treated by rubber band ligation, as well as the immediate and long-term results of this technique. METHODS: From January 2001 to December 2004, 73 consecutive outpatients with second degree haemorrhoids underwent RBL. From 1 to 3 years from the initial treatment, 73 patients were contacted by phone call to have some news about their health condition and to collect their opinion about the satisfaction of RBL technique. RESULTS: We didn't identify any major complication in our series, sometimes a temporary anal discomfort that could be controlled by low dose of NSAIDs. We report an excellent immediate benefit in 13.7% of cases, a good one in 58.9%. From 1 to 3 years after the initial procedure 82.2% of patients are either symptom free or improved and don't need any medical therapy. CONCLUSIONS: Immediate results are very good in particular for bleeding, anal pain and mucosal prolapse. Immediate and long-term results are invalidated by the concomitance of more symptoms and different results are recorded between sexes. We consider RBL a good ambulatory practice that could either get better or resolve haemorrhoidal disease or delay the invasive surgical treatment for second degree haemorrhoids.

[An abdominal Burkitt's lymphoma in acute phase. Case report]. / Il linfoma di Burkitt a localizzazione addominale con presentazione acuta. Caso clinico.

Burkitt's lymphoma is a highly malignant, aggressive and rapidly growing B-cell neoplasm, which has low long-term survival rates. Abdomen is the most frequent onset site of nonendemic Burkitt's lymphoma. The rapidity of volumetric doubling of this neoplasm frequently justifies an abdominal acute presentation, that may mime other less rare diseases. Symptoms are often misleading and make diagnosis difficult. The aim of this work is to report a case of a 13-year-old boy affected by terminal ileum Burkitt's lymphoma with hepatic metastasis, which initially was mistaken for acute appendicitis complicated by hepatic abscesses and, following a second surgical operation, for terminal-ileum inflammatory bowel disease. The rapidity of growth of this neoplasm justifies the finding, during the second surgical operation, of a mass that was not clinically manifested during first operation, carried out only a week ago. Clinical signs and instrumental investigations were not diagnostic, as well as the literature reports. The role of surgery remains controversial, and is usually limited to collection of specimens for histological diagnosis or to management of acute complications, as in our case report. Mostly treatment protocols are based on chemotherapy, because of the high sensibility of this neoplasm.

Prognostic value of tumour regression grading and depth of neoplastic infiltration within the perirectal fat after combined neoadjuvant chemo-radiotherapy and surgery for rectal cancer.

OBJECTIVE: To evaluate histological variables correlated with pathological response to chemo-radiotherapy protocols for rectal cancer and with local recurrence and survival. METHODS: From 1994 to 2003, 58 patients with rectal cancer were enrolled in a non-randomised study based on standardised treatment with radiotherapy, 5-fluorouracil, and surgical resection, followed by histological examination, including tumour regression grading and depth of neoplastic infiltration within the perirectal fat. All patients were followed up. Mean (SD) length of follow up was 55.3 (28.1) months, range 5 to 108. RESULTS: No case was found with no regression (grade 0). Tumour regression was defined as grade 1 in 24.5% of cases, grade 2 in 58.5%, grade 3 in 7.5%, and grade 4 (complete regression) in 9.5%. Neoplastic infiltration of >4 mm within the perirectal fat was found in 25.6% of cases in grade 1, 55.8% in grade, 2.7% in grade 3, and 11.6% in grade 4. In 80% cases of pT4 depth of neoplastic infiltration within the perirectal fat was >4 mm (100% were pN+), and the same spread was also found in 53.4% of pT2 and 86.2% of pT3. Pathological response was associated with regression grade (p = 0.006) and depth of neoplastic infiltration within the perirectal fat (p = 0.04). Tumour regression grading was an independent variable for pT (p = 0.0002), pN status (p = 0.00004), pathological staging (p = 0.000001), and local recurrence (p = 0.003). CONCLUSIONS: Involvement of the lateral resection margins correlates with a poor prognosis and indicates the likelihood of local recurrence of rectal cancer. Tumour regression grading and the depth of neoplastic infiltration within the perirectal fat are important prognostic factors that need to be evaluated routinely.

Surgical therapy for patients with extraesophageal symptoms of gastroesophageal reflux disease.

AIM: The last 20 years have seen a systematic reappraisal of the physiopathology and diagnosis of gastroesophageal reflux disease (GERD) and its associated typical symptoms, while less attention has been paid to correlating GERD with certain extraesophageal symptoms and the value of surgery for their treatment. The aim of this study was to determine the clinical and physiopathological features and the outcome of surgery, in a group of patients who underwent laparoscopic fundoplication for GERD with atypical symptoms, and to compare the results with another group of patients operated for GERD with typical symptoms. METHODS: Two hundred and forty-one patients were evaluated for GERD at our Digestive Physiopathology outpatients surgery from January 2001 to January 2003. Of the 36 patients who underwent laparoscopic fundoplication, 23 had the typical symptoms of GERD and 13 had atypical symptoms. Twelve months after surgery, these patients were compared in terms of 24-h pH monitoring, esophageal manometry, regression of symptoms and degree of satisfaction. RESULTS: Postoperatively, patients with atypical symptoms had a smaller increase in effective peristalsis (P = 0.06) and a more limited improvement in symptoms (54% vs 91%, P = 0.001), and they expressed less satisfaction with the surgical treatment (5.9 vs 8.2, P = 0.003). CONCLUSIONS: The results of surgery in GERD patients with atypical symptoms are worse than in those with typical symptoms. A careful preoperative work-up, based on 24-h pH monitoring, is fundamental for patients with atypical symptoms, who also need to be informed of the high likelihood of surgery proving clinically unsuccessful.

Preoperative chemoradiotherapy in cancer of the thoracic esophagus.

Surgery with or without adjuvant radiotherapy (RT) is the standard treatment of esophageal cancer. Preoperative radio- and chemotherapy (CT) have been introduced to improve prognosis. We report a phase II prospective non-randomized trial of preoperative RT (42 Gy/25) plus CT (cisplatin 20 mg/mq/day plus 5-fluorouracil 600 mg/mq/day, 1-5 weeks) for the treatment of thoracic esophageal cancer. From 1993, 50 patients were enrolled (40 men and 10 women, mean age 57 years, range 30-75 years). Squamous cell carcinoma accounted for 90% of cases; 10% were adenocarcinoma. Downstaging of the disease was obtained in 77.3% of cases; there were 13 (29.5%) complete responses (CR) and 21 (47.7%) partial responses (PR). Median survival was 28 and 25 months, respectively, for CR and partial response (PR) plus stable disease (SD) and progressive disease (PD) (P = 0.05). Progressive-free median survival was 22 and 17 months, respectively, for CR and PR + SD + PD (P = 0.08). Multimodal treatment of esophageal cancer showed promising results, although not significant, in terms of survival and disease progression for patients achieving a complete pathologic response.