[Abdominal compartimental syndrome as a complica-tion of Fournier's gangrene]. / Sindrome compartimentale addominale da gangrena di Fournier. Case report.

Analyzing a complex case and referring to the literature, the authors describe abdominal compartmental syndrome as a complication of Fournier's gangrene, stressing out the importance of an early diagnosis to perform prompt and effective treatment. The characteristic of this case is not represented only by the Fournier's gangrene rarity, but also by the appearance of an abdominal compartmental syndrome due to the gangrene extension from the scrotum to the abdominal wall and cavity through the spermatic funiculus. The treatment of the abdominal compartmental syndrome was the surgical toilette of the necrotic regions (scrotum, abdominal wall and cavity) together with an orchiectomy.

Heparin induced thrombocytopenia in patients with ventricular assistance device bridge-to-transplantation. A case series.

Heparin-induced thrombocytopenia (HIT), is a severe side effect of heparin. It occurs both in patients treated with unfractionated heparin (UFH) and in patients treated with low molecular weight heparin (LMWH). It is associated with anti-heparin/platelet factor (PF4) antibodies. HIT is a rare pathology, with rates going from 8% to 10% in patients in ventricular assist device support. The authors present three clinical cases which occurred in the Department of Anesthesiology of the Civil Hospital of Strasbourg (France) in patients receiving biventricular assistance bridge-to- cardiac transplantation. All the three patients were hospitalized for myocardial infarction. In case 1 HIT was diagnosed on VI day postoperative after a ventricular assistance device (VAD) implant. The patient was treated with lepirudin and transplanted after 73 days. In case 2 HIT diagnosis was made after 9 days receiving VAD. Also this patient was treated with lepirudin and transplanted after 48 days. Both case 1 and 2 received intra-aortic balloon pump (IABP) assistance before receiving VAD. Case 3 received VAD on XXII day of hospitalization; the patient developed HIT after 5 days, which was treated with lepirudin. He was transplanted after 66 days, but he died in course of intervention. HIT in patients undergoing VAD bridge-to-transplantation is a rare and often misdiagnosed cause of thrombocytopenia. Correct diagnosis, management and therapy are mandatory in this kind of patients, but they are not easy and standardized.

An unusual case of rectal carcinoid removed by transanal endoscopic microsurgery.

The name ''carcinoid'' was invented by Oberndorfer in 1907, when the nature of those histological entities was little understood. Usually, they were found in various locations in the gastrointestinal (GI) apparatus (67%), most of them in the small intestine (25%), appendix (12%), and rectum (14%).The techniques used for their removal are various. The authors present here a case of rectal carcinoid removed using the transanal endoscopic microsurgery technique, and referred to the diagnosis and treatment of this uncommon tumor. A 37-year-old male was admitted to the Santa Maria Hospital of Terni (Italy) with a chief complaint of intermittent pain in the lower right quadrant, that began three years ago. Complete blood count (CBC) and laboratory data as tumor markers and urinary 5-hydroxyindoleacetic acid (5-HIAA) showed no abnormalities, while urinary vanilmandelic acid level was elevate (18 mg/24 h). The patient was submitted to a colonoscopy with magnifying endoscopy and biopsy. The histological finding demonstrated a nodule characterized by cellular proliferation, with few microscopical abnormalities, arranged in small cords with a glandular pattern, separated by dense connective tissue. Histochemically the tumor cells were cytocheratins +/-, chromogranin positive, synaptophysine positive, CD56 positive and Growth Index MIB1-Ki67 which was almost zero. The patient also underwent an endoscopic ultrasonography and an Octreoscan. He was operated using a transanal endoscopic microsurgery technique. The use of Transanal Endoscopic Microsurgery (TEM) as a safe and feasible technique for exciding rectal tumors can be easily understood, for the excellent view and precise dissection. The use of new surgical devices as Harmonic Scalpel has improved the precision of this kind of approach, increasing the appropriateness of this approach compared to other kind of resection. A full diagnostic course and an immunohistochemistry are mandatory for precise diagnosis of rectal carcinoid. Careful attention must be paid to these tumors because of their unexpected behaviour.

[Laparoscopic cholecystectomy for acute cholecystitis]. / La colecistectomia laparoscopica nel trattamento della colecistite acuta.

BACKGROUND: The aim of this study is to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to determine the optimal timing. PATIENTS AND METHODS: The study was performed in two groups of 70 consecutive patients (similar in age and ASA classification), retrospectively reviewed, who had been diagnosed with acute cholecystitis and were underwent early or delayed laparoscopic cholecystectomy. In early group surgery took place within 48 hours of admission in hospital. The interval for delayed laparoscopic cholecystectomy was 8-12 weeks after medical treatment. RESULTS: In delayed group 21,4% of patients required urgent surgery after failure of conservative treatment. The most important significant difference is the total hospital stay: the early group had a significant shorter hospital stay (7 days) vs delayed group (13 days). Other differences were the conversion rate (8,6% in early group vs 12,7% in delayed group) and median the operation time (84 min. in early group vs 106 min. in delayed group). Post-operative complications developed in 6,3% in early group vs 2,6% in delayed group. CONCLUSION: The optimal treatment of acute cholecystitis is urgent laparoscopic cholecystectomy but in our experience early laparoscopic cholecystectomy increased postoperative morbidity in hospital decreased conversion rate, median operation time and hospital stay.

Acute appendicitis: a descending trend?

AIM: The diagnosis-related group (DRG) system is a prospective hospital payment system used to categorize hospital patients expected to require similar hospital services. In Italy, hospital productivity is calculated from DRG-based data coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which is a classification system for coding of diagnoses and operations for indexing medical records by diagnosis and operations. The aim of our survey was to determine the national incidence of appendectomies based on the coded summary of selected data in hospital discharge reports (HDR). METHODS: The Italian Ministry of Health online database was searched for data collected between 2001 and 2003. The search engine allows analysis by different regions but not by individual hospital. The national incidence of appendectomy was calculated using data collected from the ICD-9-CM and from the HDR. In a deeper analysis, regional data and data from individual hospitals were compared. RESULTS: The analysis revealed the incidence of appendectomy, rates of simple acute appendicitis vs complicated appendicitis, common laparotomic appendectomy vs laparoscopic appendectomy, as well as mean duration of hospitalization. CONCLUSION: The incidence of acute appendicitis has considerably decreased, whereas the rates of complicated appendicitis have increased because of longer diagnostic and therapeutic delay, inappropriate antibiotic therapy and upclassifying of diagnosis and procedures in the HDR (ICD-9-CM) in order to obtain a ''wider impact'' on DRG.

Mesorectal microfoci adversely affect the prognosis of patients with rectal cancer.

PURPOSE: Mesorectal involvement is a common feature in rectal tumors. Neoplastic foci can be identified at pathologic examination of the mesorectum, but their incidence and prognostic significance remain to be defined. METHODS: A series of 77 patients with extraperitoneal rectal cancer, resected with total mesorectal excision, entered the study. After fixation, the excised specimens were submitted to serial transverse sections and staining. Direct tumor infiltration, lymph node involvement, and neoplastic microfoci in the mesorectum were investigated. Patients with mesorectal foci were compared with those without deposits with regard to clinical and pathologic parameters; different patterns of foci (endovasal, endolymphatic, perineural, isolated) were also considered. Univariate and multivariate analyses were used to evaluate the impact on survival rate. RESULTS: Neoplastic mesorectal involvement was found in 64 patients (83.1 percent). Direct tumor infiltration was detected in 66.2 percent, node involvement in 28.6 percent, microscopic foci in 44.2 percent of cases (endovasal in 11.7 percent, endolymphatic in 15.7 percent, perineural in 26 percent, isolated in 14.3 percent). In 7 cases (10.9 percent) microfoci alone (without any kind of other mesorectal involvement) were detected. Deposits were found in 18.8 percent of TNM Stage I tumors, in 46.9 percent of Stage II and in 59.3 percent of Stage III cancers. Similar incidence was found in patients treated with integrated therapies and surgery alone (43.3 vs. 44.7 percent, P = not significant). Poorer median (44.5 vs. 57 months, P = 0.04) five-year overall survival rate (43.4 vs. 63.3 percent, P = 0.016) and disease-free survival rate (43.3 vs. 57.7 percent, P = 0.048) were observed in patients with microscopic foci compared with those without deposits. Tumor configuration was found to be a independent prognostic factor for both overall and disease-free survival rates; furthermore, endolymphatic, perineural, and isolated foci significantly affected overall survival rate, while TNM staging affected disease-free survival rate. CONCLUSIONS: The incidence of neoplastic foci in the mesorectum is high, even in early staged tumors and despite aggressive preoperative treatment. They seem to affect prognosis. Such features should, therefore, be considered when local excision of the tumor is planned. Presence of mesorectal foci should modify conventional staging of the rectal tumor.