Evaluation and management of chronic anorectal and pelvic pain syndromes: Italian Society of Colorectal Surgery (SICCR) position statement.

Chronic pelvic pain is a hidden issue which needs to involve many different usually uncoordinated specialists. For this reason there is a risk that treatments, in the absence of well-defined pathways, common goals, and terminology, may be poorly effective. The aim of the present paper is to summarize the evidence on anorectal pelvic pain, offering useful evidence-based practice parameters for colorectal surgeons' daily activity. Analysis of chronic anorectal and pelvic pain syndromes, the diagnostic and clinical optimal needs for evaluation, and the innumerable low evidence treatments and therapeutic options currently available suggests that a multimodal individualized management of pain may be the most promising approach. The limited availability of dedicated centers still negatively affects the applicability of these principles.

Acute acalculous cholecystitis on a COVID-19 patient: a case report.

INTRODUCTION: We report an extremely rare case of acute acalculous cholecystitis on a COVID-19 patient. In our knowledge, this is the first report of laparoscopic cholecystectomy performed on a COVID-19 patient. PRESENTATION OF CASE: A COVID-19 patient was diagnosed with acute acalculous cholecystitis and a multidisciplinary team decided to perform a percutaneous transhepatic biliary drainage (PTBD) as the first treatment. SARS-CoV-2 RNA was not found in the bile fluid. Because of deterioration of the patient's clinical conditions, laparoscopic cholecystectomy had to be performed and since the gallbladder was gangrenous, the severe inflammation made surgery difficult to perform. DISCUSSION: Acalculous cholecystitis was related with mechanical ventilation and prolonged total parenteral nutrition, in this case the gangrenous histopathology pattern and the gallbladder wall ischemia was probably caused by vascular insufficiency secondary to severe acute respiratory distress syndrome of COVID-19 pneumonia. The percutaneous transhepatic gallbladder drainage (PTBD) was performed according to Tokyo Guidelines because of high surgical risk. Laparoscopic cholecystectomy was next performed due to no clinical improvement. The absence of viral RNA in the bile highlights that SARS-CoV-2 is not eliminated with the bile while it probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhoea. CONCLUSIONS: Although the lack of evidence and guidelines about the management of patient with acute cholecystitis during COVID-19 pandemic, laparoscopic cholecystectomy, at most preceded by PTGBD on high surgical risk patients, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patients.

Cystic pancreatic tumors: should we resect all of them?

OBJECTIVE: Pancreatic cystic tumors are relatively rare tumors and only 1% of them are malignant. They are often asymptomatic and detected as incidental findings through diagnostic imaging. Currently there are no universal guide lines for the correct clinical approach to pancreatic cystic lesions. Cross-sectional imaging demonstrates some typical morphological features that determine the pre-operative diagnosis of the pancreatic cystic lesions (serous or mucinous cystadenoma, intraductal papillary mucinous neoplasms). In addition, endoscopic ultrasonography permits the collection and analysis of the fluid content. The aim of this paper is to describe our case load in the management of pancreatic cystic neoplasms and propose some criteria for choosing between surgical or conservative approaches. PATIENTS AND METHODS: 12 patients with pancreatic cystic neoplasms were retrospectively evaluated. They were studied using cross-sectional imaging modalities (computed tomography and magnetic resonance); endoscopic ultrasonography was performed in 7 patients. RESULTS: In each patient a careful evaluation of several factors (age, comorbidity, imaging features, symptoms, life expectancy) conditioned our clinical decision. Among our 12 patients, surgical resection was performed in 7 cases. DISCUSSION: The treatment of pancreatic cystic lesions is still a dilemma because even in the presence of malignant potential, pancreatic surgery remains very complicated and demolitive. Many factors need to be considered in the management of cystic pancreatic tumors. The most important include histological type, location, size, age and clinical condition of the patient. CONCLUSIONS: A correct multidisciplinary pre-operative diagnosis is mandatory. Surgery should only be performed in selected cases.

Laparoscopic resection of an abdominal wall desmoid using a modified suture traction technique: the "marionette trick".

Desmoids are rare mesenchimal tumors that may originate also inside the abdomen or in the abdominal wall. These tumors are biologically characterized by a tendency to local growth, and only rarely are they able to develop distant metastases. Surgical excision usually is the best treatment with a chance of a cure. In the few reports on intraabdominal or abdominal wall desmoids, open surgery always was performed. The first case of successful laparoscopic resection of a symptomatic anterior wall desmoid tumor with intraabdominal growth is reported. During the procedure, it was difficult to mobilize and grasp the mass using the common laparoscopic instruments, but with the help of the "marionette trick," modified suture traction technique, the tumor could be removed easily using only three trocars. With four traction sutures minimizing the wall trauma, the trick made it possible to mobilize the mass in at least, seven directions, according to the principles of physical forces and vectors. This simple trick can be helpful for other common laparoscopic procedures, avoiding the insertion of sometimes ineffective instruments through more traumatic trocars.

Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial.

BACKGROUND: Continuous veno-venous haemofiltration is increasingly used to treat acute renal failure in critically ill patients, but a clear definition of an adequate treatment dose has not been established. We undertook a prospective randomised study of the impact of different ultrafiltration doses in continuous renal replacement therapy on survival. METHODS: We enrolled 425 patients, with a mean age of 61 years, in intensive care who had acute renal failure. Patients were randomly assigned ultrafiltration at 20 ml/h-1/kg(-1) (group 1, n = 146), 35 ml/h(-1)/kg(-1) (group 2, n = 139), or 45 ml/h(-1)/ kg(-1) (group 3, n = 140). The primary endpoint was survival at 15 days after stopping haemofiltration. We also assessed recovery of renal function and frequency of complications during treatment. Analysis was by intention to treat. RESULTS: Survival in group 1 was significantly lower than in groups 2 (p = 0.0007) and 3 (p = 0.0013). Survival in groups 2 and 3 did not differ significantly (p = 0.87). Adjustment for possible confounding factors did not change the pattern of differences among the groups. Survivors in all groups had lower concentrations of blood urea nitrogen before continuous haemofiltration was started than non-survivors. 95%, 92% and 90% of survivors in groups 1, 2 and 3, respectively, had full recovery of renal function. The frequency of complications was similarly low in all groups. INTERPRETATION: Mortality among these critically ill patients was high, but increase in the rate of ultrafiltration improved survival significantly We recommend that ultrafiltration should be prescribed according to patient's bodyweight and should reach at least 35 ml/h(-1)/kg(-1).

Efficacy and safety of elective laparoscopic cholecystectomy in elderly: a case-controlled comparison with the open approach.

BACKGROUND: Minimally invasive laparoscopic surgery is the method of choice for the surgical treatment of gallbladder disease. However, surgery of the biliary tract in the elderly is often associated with high morbidity and mortality. PATIENTS AND METHOD: To evaluate the efficacy and safety of the laparoscopic cholecystectomy in the elderly with symptomatic, uncomplicated gallbladder disease, we retrospectively compared the records of 24 consecutive patients over 70 years of age with symptomatic uncomplicated gallbladder disease, who underwent elective laparoscopic cholecystectomy, with a similar cohort of patients who underwent elective open cholecystectomy for the same indications. RESULTS: In the laparoscopic group we found a significantly low incidence of postoperative complications, low analgesics and antibiotics administration, rapid recovery, short length of stay and considerable cost savings. CONCLUSION: We conclude that elective laparoscopic cholecystectomy in elderly with uncomplicated gallbladder disease is safe and effective and we suggest that it may become the surgical procedure of choice.

[Cystic lymphangioma of the pancreas: clinical case and review of the literature]. / Linfangioma cistico del pancreas: caso clinico e revisione della letteratura.

Cystic lymphangioma is a rare benign tumor that occurs more often in children with different localizations. Abdominal localization and its development may produce symptoms and clinical features of acute abdomen leading to problems in the differential diagnosis. The Authors report a rare case of pancreatic lymphangioma in a nine years old child resolved by surgical treatment. A review of the literature concerning problems of diagnosis and treatment is also presented.

TINU syndrome associated with reduced complement levels.

The TINU syndrome (tubulointerstitial nephritis and uveitis) was first described by Dobrin et al. in 1975. Since then, more than 50 cases have been documented each with diverse immunopathogenetic and genetic characteristics. The aim of this report is to describe a case of TINU associated with reduced complement levels. We profile a 48-year-old white female with persistently reduced C4 complement levels during the acute phase of the pathology and with an unaltered immunologic profile. Renal biopsy evidenced a significant lymphocytic interstitial infiltration. Immunohistochemical studies of the interstitium infiltrates was positive for the presence of the T (CD3) markers (CD4 > CD8). Steroid therapy yielded a complete regression of the symptomatology with normalization of the complement levels. We suggest that it is possible to hypothesize that the various immunologic alterations associated with TINU, including the transient reduction complement levels, may be secondary to multiple inflammatory mechanisms which express themselves throughout the pathology.

Totally implantable venous access devices implanted surgically: a retrospective study on early and late complications.

BACKGROUND: The techniques used for the implantation of totally implantable venous access devices (TIVADs) are the percutaneous approach and surgical cutdown; however, the choice is still controversial. HYPOTHESIS: The surgical cutdown approach may be beneficial to reduce the rate of complications. DESIGN: Retrospective review. SETTING: A university hospital and a tertiary referral center. PATIENTS: Patients undergoing a TIVAD implant at the First Surgical Clinic of the University of Catania in Catania, Italy, between January 1995 and December 1999, were considered for the study. All of the devices were implanted in an operating room under fluoroscopic control. The vein of choice was the cephalic vein. When the cephalic vein was not suitable for implantation, the external jugular vein or the axillary vein and its branches were used. The percutaneous approach to the subclavian vein or internal jugular vein was considered a last resort to implant a catheter. RESULTS: During the study period, 346 TIVADs were implanted in 344 patients. The procedure was performed with local anesthesia in 341 cases (98.5%), and only 2 patients (0.6%) required sedation for psychological reasons. Three patients (0.9%) had their TIVAD placed during a laparotomy. In 326 patients (94.2%), the devices were implanted in the cephalic vein. In the remaining cases, other veins were used with surgical cutdown. The mean time for the procedure was 15 minutes. Percutaneous access was never used, and no early mechanical complications were recorded. Only 6 patients (1.8%) in our study group had late complications (1 case of migration of the catheter, 2 cases of infection, and 3 cases of withdrawal occlusion). The catheter life ranged from 6 to 1487 days (mean time, 348 days). CONCLUSION: Our results confirm the safety, speed, and low cost of the open cutdown technique. This surgical procedure avoids both early and late complications that frequently occur with percutaneous access. Surgical cutdown should be considered the technique of choice to implant the TIVAD, especially in cancer patients.

Experimental anaesthesiologic protocol for porto-intracaval shunt for liver total vascular exclusion: preliminary study in the rabbit.

The aim of this study was to evaluate the effects and interference of different anaesthetic techniques in rabbits undergoing liver total vascular exclusion using a porto-intracaval shunt. Twenty New Zealand rabbits were divided in three groups: group A receiving diazepam as premedication, ketamine + atropine for induction and maintenance of anaesthesia and undergoing a porto-intracaval shunt operation; group B receiving midazolam as premedication, ketamine + fentanyl + atropine for induction and maintenance of anaesthesia and undergoing a porto-intracaval shunt operation; group C receiving the same drugs as group B but undergoing a simple portal and caval clamping. The following parameters were studied: efficacy of premedication, vital parameters before and after clamping and insertion of the shunt, mean time to clamp and insert the shunt, mean survival time after clamping (group C) or activation of the shunt (groups A and B). Midazolam was significantly better for premedication; there was no statistically significant difference between groups A and B for the vital parameters, for the time necessary to clamp and insert the shunt, for the intraoperative course, and for the mean survival time. The absence of a statistically significant difference between groups could be due to the low number of animals used in the study. There is actually evidence that a correct anaesthesiologic protocol, especially referring to analgesia and fluid management, improves the outcome of operated animals. Surely further studies, possibly conducted on a larger number of animals, are required to evaluate better the results observed and to consider applying these data and this experience to humans.

Effectiveness of porto-intracaval shunt to reduce the negative effects of portal and caval clamping in the rabbit.

In performing experimental liver surgery, it is difficult to prolong anhepatic time because the animals do not tolerate prolonged portal and caval clamping. To counteract prolonged venous stasis, the authors previously developed a simple porto-intracaval shunt. The shunt consists of a self-constructed inverted Y silicone tube. The effectiveness of this shunt was studied comparing two groups of 10 rabbits with shunt (S) versus those with clamped portal and inferior caval vein (C). In the group of rabbits that underwent porto-intracaval shunt, the results concerning intraoperative mortality, intraoperative increase in distal portal vein pressure, and incidence of the histologic signs of gut damage were clearly improved. The proposed porto-intracaval shunt was therefore effective in reducing some principal negative effects of portal and caval clamping. This type of porto-intracaval shunt can be therefore useful allowing improvement of experimental models concerning liver surgery in little animals.

Practice pattern and treatment options for kidney patients in a single North Italian nephrology center.

The experience and the current practice of a single center located in northern Italy is reported. The center of Vicenza is a self-standing nephrologic unit serving a population of about 300,000 individuals. The overall province counts approximately 800,000 individuals and some of them are referred to our center from peripheral hospitals for renal transplantation and/or particular pathologic conditions. The center offers an integrated approach to the treatment of uremia including hemodialysis (HD), peritoneal dialysis (PD), and renal transplantation. In HD and PD, the most peculiar aspect is the treatment personalization that leads to numerous types of applied therapies and technologies. The policy of the center is based on the belief that the nephrology team has a substantial influence on the outcomes of dialysis patients. A large number of treatment options are available. Special care is placed on the delivery of an adequate amount of dialysis, but the fractional clearance of urea in relation to volume (Kt/V) is seen as a prerequisite and other factors are considered important. Reduction in mortality and morbidity is largely dependent on beginning therapy early in the course of renal treatment. The attainment of appropriate hemoglobin concentrations, good nutrition, good control of calcium and phosphorus metabolism, lipids, and blood pressure, is considered of great importance. Beyond all these factors the time spent by the physician with the patient is considered one of the major factors influencing quality of care. The particularly low mortality of the center (6%/yr) may also be ascribed to a lower incidence of diabetes and other comorbidities.

[Critical ischemia of the diabetic patient]. / L'ischemia critica nel paziente diabetico.

BACKGROUND: Critical ischemia of the lower limbs is the final result of diabetic arteriopathy. The surgeon is more and more forced to choose between amputation d emblée and the attempt to revascularization in very old patients and in deficient general conditions. Shall we point out some principle to address our strategy? METHODS: To answer this question we reviewed retrospectively our surgical choices and the results obtained during two years, from January 1997 to December 1998 (medium follow-up 11.3 months), at the Emergency Division of the Cannizzaro Hospital of Catania. In this period 143 diabetic patients were selected by our ambulatory. Of these, nineteen had a critical lower limb ischemia and therefore were submitted to a revascularization and/or amputation. All the revascularized patients were controlled by Doppler-sonography immediately after operation and then daily, till their discharge. Controls were done at the first, third, sixth month and after one year, except for patients who complained a new objective or subjective ischemic symptomatology. RESULTS: The primary patency rate was 84.2% and the secondary patency rate was 89.4%. The amputation rate due to the procedure failure was 5%. The complications were three: two graft infections (10.5%) and one early thrombosis of a femoro-popliteal bypass graft, due to technical defect (5.2%). Perioperative mortality rate was 15.7%. CONCLUSIONS: These results, if related with those reported in the letterature about amputations, are in favour of the attempt to revascularization.