Colocutaneous fistula through ulcerative colitis and cancer to the pyoderma gangrenosum: a never-ending story for a single patient. Case report.

BACKGROUND: Inflammatory bowel diseases may be associated with many extraintestinal complications, that in some cases can represent the first onset of these disorders. In particular during the course of the disease, Ulcerative Colitis develops extraintestinal manifestations very frequently. One of the rarest is pyoderma gangrenosum, a noninfectious neuthrophilic dermatosis, that can involve most commonly legs but also other parts of the skin or mucosas. It can be idiopathic or associated with gammopathies, vasculitis, chronic arthritis or, like in our case, with inflammatory bowel disease and malignancies. CASE PRESENTATION: A 38-year-old man was referred to our Department with a colo-cutaneous fistula in the left quadrant of abdominal wall. In the anamnesis he reported a trauma during a soccer match three weeks before. Through a CT scan and endoscopy with biopsy an inflammatory bowel disease with a segmental colitis and stenosis was diagnosed. After medical therapy, an initial radiological drainage and a period of parenteral nutrition, he underwent a left hemicolectomy. Despite the previous endoscopic biopsy the histopathological examination put in evidence not only inflammatory disease (in particular Ulcerative Colitis) but also a colorectal tumor pT4pN0. After the full recovery before chemotherapy he has developed on the chest and on the abdomen some painful nodules, with central necrosis, one of those in contact with one of the ribs. Through TC and RM it was impossible to understand the precise nature of these skin lesions. With biopsy a pyoderma gangrenosum was diagnosed and treated until complete resolution. DISCUSSION AND CONCLUSION: Management of inflammatory bowel diseases can be a true challenge, not only for the intestinal manifestations, but also for all the other features not related to gut. In some cases the same patient can develop many complications, such as malignancies or rare cutaneous diseases. Despite the initial surprise for such a weird evolution in a same patient, from fistula to inflammatory disease to cancer and finally to pyoderma gangrenosum, to face every single complication following consolidated diagnostic and pathological paths has been the correct strategy for controlling the disease.

Ketamine for chronic non-cancer pain: A meta-analysis and trial sequential analysis of randomized controlled trials.

BACKGROUND: Ketamine has been suggested to be efficient in relieving chronic pain. However, there is inconsistency across studies investigating the effect of ketamine for chronic pain management. We aimed to perform a meta-analysis in order to assess the efficacy of this compound during chronic non-cancer pain conditions. METHODS: The study consisted in a meta-analysis of clinical trials comparing ketamine to a placebo during chronic non-cancer pain. The primary endpoint of this study was pain relief 4 weeks after the beginning of treatment. Secondary outcomes were: pain relief 1, 2, 8 and 12 weeks after the beginning of treatment and incidence of psychedelic manifestations. RESULTS: Six studies were included in this meta-analysis. Overall, 99 patients received ketamine and 96 received placebo. Ketamine did not decrease pain intensity at 4 weeks (MD (on a 0 to 10 scale) = -1.12 [-2.33, 0.09], GRADE evidence: very low). However, analysing studies with no high-risk bias found ketamine to decrease pain intensity at 4 weeks and increased the level of GRADE evidence to moderate. Trial sequential analysis confirmed the overall result and revealed the lack of power of this meta-analysis. Ketamine also decreased pain intensity at all other evaluated points in time. Ketamine increased the incidence of psychedelic manifestations in comparison to placebo. CONCLUSION: Results of this meta-analysis found moderate evidence suggesting the efficacy of ketamine during chronic pain. Further studies are warranted to conclude about the effect of ketamine during chronic pain conditions and to determine optimal administration regimes of this agent during this condition. SIGNIFICANCE: Ketamine has been found interesting for managing chronic pain. We performed a meta-analysis aiming to confirm those results. Ketamine was found efficient in alleviating pain up to 12 weeks after the beginning of treatment. However, overall evidence favouring the use of this compound was very low.

Modified transverse coloplasty pouch: new reconstruction techniques after total mesorectal excision. Our experience.

AIM: The incidence of rectal cancer continues to rise. The functional results after complete Total Mesorectal Excision (TME) depend on the segment of colon used for reconstruction of colonic continuity and the form, the volume and the functional proprieties of the "neorectum". The aim of our study is evaluate the efficacy of our Modified Transverse Coloplasty Pouch (MTCP) after the treatment of low rectal cancer in terms of functional outcomes and quality of life. PATIENTS AND METHODS: The study included 136 patients, underwent TME from January 2007 to December 2016 with diagnosis of extraperitoneal carcinoma of the rectum. The average distance of the tumor from the dentate line was 5.6 cm. Our follow-up protocol included functional outcome evaluation at 7th post-operative day (POD), 2nd month, and 6th month after the surgery. RESULTS: All patients (M/F 84/52) underwent anterior rectal resection (TME) with MTCP. Frequency of bowel movements per 24 hours in the studied patients compared at 7th POD, 2 months, and 6 months. Since the first post-operative weeks there is an encouraging reduction of the frequency of bowel movements. CONCLUSION: Modified Transverse Coloplasty Pouch (MTCP) had better functional results and quality of life compared to patients with a Colonic J Pouch (CJP) and traditional Transverse Coloplasty Pouch (TCP).

Pilonidal disease mimicking anterior anal fistula and associated with posterior anal fistula: a two-step surgery. Case report.

AIM: Anal fistula is a common disease originated from abscess according the cryptoglandular theory. A rare etiology is the pilonidal disease. In our case we observed a pilonidal disease mimicking an anterior perianal fistula, associated with another posterior anal fistula. CASE PRESENTATION: A 36-year old man was referred to our department with an anal fistula with an anterior opening. Despite the clinical examination and the endoanal ultrasound, only during the surgery we discovered the origin of the anterior fistula from a misdiagnosed pilonidal sinus. There was also a posterior anal fistula in communication with the same abscess of the anterior one. We performed a two-step surgery with a first fistulectomy of the anterior tract, a drainage of abscess and the positioning of a seton for the posterior fistula. After about one month and the fall of the seton we evaluate the good healing of posterior anal fistula and excised the residual pilonidal sinus. CONCLUSION: This misdiagnosed pilonidal disease created in our clinical report a true challenge. Our goal was to eliminate as much disease as possible, but also to avoid major complications or recurrences. We refused an aggressive approach and chose a two-step surgery, with in the first approach not only a demolitive time but also a reconstruction to facilitate healing, and in the second time the complete eradication of the pathology.

Endoscopic findings and psychometric abnormalities: what is the relationship in upper endoscopic outpatients?

BACKGROUND: Psychological disorders are often associated with diseases of the upper digestive tract. Although emotions can influence gastrointestinal function in healthy individuals, psychological setting in upper gastrointestinal patients are unclear. We evaluate the psychological alterations prevalence in outpatients submitted to upper endoscopy. MATERIALS AND METHODS: A total of 130 patients (50 males and 80 females; mean age 54±17 years) submitted to upper gastrointestinal endoscopy, were enrolled over the period May 2009 - September 2010. Subjects were asked to complete questionnaires before endoscopic examination. Alexithymia, anxiety, depression and coping style were assessed using the Toronto Alexithymia Scale, Spielberger Trait Anxiety Inventory, Beck Depression Inventory and Coping Inventory for Stressful Situations, respectively. RESULTS: Coping impairment, Alexithymia, Anxiety and Depression were found respectively in 80.3%, 25.4%, 24.6% and 17.2%, often in association. Task-oriented, emotion-oriented and avoidance-oriented alterations were found in 41.8%, 40% and 30.6%, respectively. No correlations were demonstrated between diagnosis of upper gastrointestinal disease and psychometric results. CONCLUSIONS: In our study, a high prevalence of psychometric alterations in gastrointestinal outpatients was unconnected with endoscopic findings, especially considering coping style alterations. This aspect should be taken into account in patients management and a long-term follow-up should clarify a possible role of these factors in patients prognosis and compliance.

Prevention of complications during reoperative thyroid surgery.

BACKGROUND: Thyroidectomy performed by an experienced surgeon is associated with a low incidence of recurrent laryngeal nerve injury and permanent hypoparathyroidism. During reoperative thyroid surgery there is a higher technical risk because detection and preservation of the recurrent laryngeal nerves and parathyroid glands are more difficult than in the primary surgery. AIM: Our retrospective cohort study was to assess short- and long-term complications associated with reoperative thyroid surgery in order to suggest a technical approach to lower the morbidity rate. MATERIALS AND METHODS: From January 2005 to September 2013, 745 patients underwent surgery for thyroid disease. Before surgery all patients underwent clinical examination, laboratory blood tests, hormonal assays, neck ultrasound, chest radiography and indirect laryngoscopy. Patients were followed up at 1, 3, 6 months and then annually after operation with hormonal assays, blood tests and neck ultrasound. RESULTS: Eighty (10.7%) out of 745 patients (mean-age= 52.5 years; age-range 18-80) underwent reoperative surgery for recurrent thyroid disease. The primary treatments were enucleoresection (11.2%), thyroid lobectomy(56,3%), thyroid lobectomy with isthmectomy(10%) and subtotal thyroidectomy (22,5%). In the reoperative surgery group (Group Re) the transient RLN complications were 1.3% compared to 0.2% in the primary surgery group (Group P) (p= 0.51). The incidence of temporary hypocalcemia was 45% in the reoperative surgery group vs. 42.7% in the primary surgery group (p=0.72). CONCLUSIONS: Reoperative surgery should be reserved to experienced surgeons. However, even in this case, when surgical maneuvers reserved for primary surgery are applied, then this surgery is associated with a low complications rate.

Extraskeletal Ewing's Sarcoma: insight into a ten years follow-up.

Extraskeletal Ewing's sarcoma is a rare malignant soft tissue tumor, classified within the Ewing's Sarcoma Family Tumors. While the classical Ewing's Sarcoma affects mainly the bone during youth, the Extraskeletal histotype differs for age incidence, primary location and prognosis. Peak incidence and typical location are during adolescence and in the extremities respectively. We report a 30 year old woman case with a positive outcome after ten years from first diagnosis of Extraskeletal Ewing's sarcoma. Treatment was achieved through surgical resection plus adjuvant chemoradiotherapy derived from EW93 and IRS III trials. Conclusion. Our report represents an unusual case due to age of presentation, neoplasm location and long survival reached. In last decades several trials results demonstrated that long survival could be achieved by combined surgery and adjuvant multi-drug treatment.

Gastrointestinal stromal tumors treatment in the Imatinib era. The role of fair indication.

AIM: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Surgery remains the elective treatment. We retrospectively compared two group of patients, who underwent surgery for GIST before and after Imatinib advent in order to analyze the recurrence and survival rate. METHODS: Two patient groups who underwent surgery for GIST, from January 1997 to December 2002 (Pre-Imatinib group) and from January 2003 to December 2008 (Post-Imatinib group) were compared. Patients were evaluated on the base of gender, age, clinical manifestations, primary location and metastasis positivity, tumor size, mitotic index, immunoreactivity for CD117 and the outcome, including date of death. RESULTS: In the Pre-IM group only one patient died for prostate cancer, 12 months after operation, the other died because of GIST with a 24.6 months of median survival rate (range 15-51). In the remaining 12 patients the median follow up period was 55 months (range 6-152 months). In the Post-IM group the mean follow up was 50.7 months (range 26-74) and they are still being assessed for oncological as well as surgical treatment. CONCLUSION: Early diagnosis and radical resection remain the standard of cure for GISTs. To date, the use of Imatinib lead to its utilization as adjuvant and neo-adjuvant therapy in adults. Our experience suggests that there is a correlation between the mutational status of KIT and clinical outcome. These aspects should be explored for targeted therapy that can effectively combine biological therapy to surgery.

[Despite corrective measures, will there still be a lack of anaesthetists and intensive care physicians in France by 2020?]. / La démographie médicale des anesthésistes réanimateurs est-elle encore compromise en France à l'horizon 2020 ?

OBJECTIVES: the demographic decline in the Anaesthesia and Intensive Care practitioners predicted for 2020 may bring into question the speciality's vocation, and indeed peri-operative care as a whole in France. The objective of this study is to assess the French Anaesthetist and Intensive Care physicians' demographics in 2010, and predicted numbers for 2020 taking into account recently initiated corrective measures. METHODS: data originating from the CFAR-SFAR-INED French medical demographics survey(1), the French General Medical Council, and various studies and projections published by the INED and the DREES(2) were collected and analysed. Factors were then identified that were likely to affect personnel numbers, speciality training requirements and the demand for patient care. RESULTS: french General Medical Council data is the most reliable and reports 9692 Anaesthetists and Intensive Care physicians practising regularly in France on the 1(st) of January 2009. Of those, 9,391 (96.9 %) were practising on the mainland. Personnel growth reduced due to the effect of specialist training selection procedures: the percentage of doctors entering Anaesthesia and Intensive Care training dropped from 12.7 % per year in 1960 to 1.5 % in 1990. Since 2002, personnel in regular practice dropped by 1.1 % per year. Relatively few doctors were leaving the profession, the decrease was due to the reduction in the numbers entering practice: 222 per year on average from 1988 through 2004, compared to 355 per year for the two preceding decades (1971 to 1987). Anaesthetists and Intensive Care physicians are growing older; the average age increased from 42.8 years of age in 1989 to 51 on the 1(st) of January 2009. Further evidence of this trend is that the number of practitioners less than fifty years of age continues to decrease; just 47.5 % in 2005 compared with 80 % in 1989. 5,139 anaesthetists between 50 and 64 years of age will leave the profession before 2020, over half (52.3 %) of the total practising in 2005. Practitioner density increased from 13.1 Anaesthetists and Intensive Care physicians per 100,000 inhabitants in 1989 to 16.2 in January2006. If only those in regular practice are considered, density is stable at 15.3 per 100,000 inhabitants as of 1(st)January2009. The most recent 2009 projections predict a 13 % decrease in the number of practitioners between 2006 and 2015, and a 16 to 20 % decrease by 2020. Initial projections in 1991 and further projections in 1999 predicted 50 % and 35 to 50 % decreases by 2020. Numerous factors could amplify this reduction in the absence of increased training efforts. These factors include population growth (+6 to 7 % by 2020), the increasing health care demands of an ageing population (+15 %), medical progress, the increasing feminisation of the medical workforce, projected retirements and reductions in migratory flows. CONCLUSION: despite increasing training throughput and increasing medical immigration, Anaesthetists and Intensive Care physicians in France are ageing noticeably and reducing in number. This foreshadows further personnel reductions in the future. A demographic catastrophe may well have been avoided; a more moderate reduction in personnel persists for 2020 with an ongoing risk of numerical inadequacy with respect to needs. This situation justifies a further increase in training throughput, along with adaptations in the provision of care, so as to ensure maintained care standards.

[Five-years experience of Emergency Endoscopic Unit at Policlinico "Umberto I" University "La Sapienza" of Rome]. / Analisi dell'attività quinquennale del Servizio di Pronta Reperibilità Endoscopica dell' Azienda Policlinico "Umberto I" dell'Università degli Studi di Roma "La Sapienza"

A second level hospital must assure to the patients a 24 hours service of emergency endoscopy. Since 1989 in the Policlinico 'Umberto I' University 'La Sapienza' of Rome, a dedicated operative unit is active. The Authors present their experience of last five years (2001-2005). The endoscopic diagnosis for appropriate therapeutics reduced time and costs of the hospitalization. The Endoscopic Operative Unit resolved the emergency in two/four hours. Neverthless, in some cases, the referall to Unit was not appropriated.

[Modern indications on the medical treatment of symptomatic diverticular disease]. / Moderni orientamenti nel trattamento medico della malattia diverticolare sintomatica.

Authors refer about their experience on treatment of symptomatic diverticular disease both with antibiotic and anti-inflammatory drugs. They confirm the observation of other Authors on effectiveness of this new therapeutic approach versus traditional antibiotic therapy.

[National survey in France about continuing medical education among anaesthesiologists]. / Enquête nationale sur la formation médicale continue des anesthésistes-réanimateurs.

STUDY DESIGN: The aim of this study was to assess how French anaesthesiologists perform continuing medical education (CME). METHODS: A 73 items survey was mailed to 1,000 anaesthesiologists (11% of anaesthesiologists population) of geographic, gender and institution representative of national anaesthesiologist demography. A second mail was sent to non-responders, 6 weeks later. RESULTS: The answer rate was 40.8% and the sample of responders appeared to match the French anaesthesiologist population. Seventy-two percent of surveyed anaesthesiologists were affiliated to the French society of anaesthesia-intensive care and 24% to other medical societies. Attendance to French congresses was 81% and miscellaneous congresses were equally appreciated in terms of quality. Only 17% of surveyed anaesthesiologists attended international congresses. Multi-thematic congresses were preferred by 67%. The annual time devoted to congresses was 6 days (median) with additional 4 days (median) reserved for practical courses. French medical journals and international journals had a reading rate of 89 and 37%, respectively. For 61% of responders CME was funded by institutional grants. Internet CME use was found in 73% of anaesthesiologists. Time and money were the two most frequent reasons invoked for CME restriction. CONCLUSION: CME is a broadly shared activity, which still remains focussed on national resources.

Demography of French anaesthesiologists. Results of a national survey by the French College of Anaesthesiologists (CFAR) and the French National Society of Anaesthesia and Intensive Care (SFAR), supported by the National Institute for Demographic Studies (INED).

BACKGROUND AND OBJECTIVE: The perception of a looming manpower shortage led the French College of Anaesthesiologists (CFAR) and the French Society of Anaesthesia and Intensive Care (SFAR), with assistance from the National Institute for Demographic Studies (INED), to conduct a national survey of French anaesthesiologists in order to determine precise physician characteristics data, analyse professional practices and project future service provision. METHODS: The survey was based on self-administered individual questionnaires, approved by the National Committee on Informatics and Freedom (CNIL). The survey was carried out at the end of 1998 among 1484 hospitals (590 public and 894 private), under the supervision of local referees and regional co-ordinators. RESULTS: Of 9741 anaesthesiologists' posts, 5694 (58%) are in public hospitals, 3569 (37%) in private practice and 478 (5%) in private hospitals within the National Health Service, i.e. the participant au service public hospitalier (PSPH). Complex validation of the results was necessary to account for the missing responses and multiple sites of activity. The survey identified 8876 specialists practising anaesthesia and intensive care in France at the beginning of 1999, including 216 in French overseas territories. This figure is consistent with that published by the Medical Council (Ordre des Médecins) on 1 January 1999, identifying 8950 anaesthesiologists in France, including 234 in the overseas territories. Annual growth in the anaesthesiologist population has fallen from 9% pre-1989 to 0% in 1999. Male anaesthesiologists outnumber females (35.7%). The average age has risen from 42.8 yr in 1989 to 45.9yr in 1999. The age distribution of anaesthesiologists has become bell shaped, reflecting reduced numbers of younger practitioners. There are currently 14.75 anaesthesiologists per 100 000 people (compared to 12.9 in 1989), a figure slightly above the European average, but there is considerable geographical inequality between the north and south of France, with increased concentrations in large cities that contain university hospitals. CONCLUSIONS: Future service provision must take account of falling numbers of new anaesthesiologists and an increase in retirements, but must also include changes in working practices, such as the European Working Time Directive. If anaesthesia manpower shortages are to be avoided, there must be a restructuring of the work-place, a redefinition of tasks and improved management of working time.

[Breath test as non-invasive assessment for the initial screening of non-ulcerous dyspepsia]. / Il Breath Test come indagine non invasiva di scelta per lo screening iniziale della dispepsia non ulcerosa.

Considering the important role of Helicobacter Pylori (Hp) in the most common gastro-intestinal pathologies, the Authors want to test the effectiveness of a non-invasive diagnostic technique for detection of the Hp in the gastric mucosa. At the end of experience they think, like the most of Literature, that the Breath Test, concerning sensibility and specificity, represent the gold standard for detection of the Hp.