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.

[Ectopic pancreas in Meckel's diverticulitis: a description of a new clinical case]. / Pancreas ectopico nel diverticolo di Meckel: descrizione di un caso clinico.

Ectopic pancreas is a rare congenital abnormality probably due to a derangement of embryologic development of digestive tract. Its frequency is reported in the literature between 0.5-14% predominantly distributed in the stomach, duodenum, jejunum. Such condition is extremely difficult to be diagnosed, in fact most of the case of ectopic pancreas are an accidental finding. We describe a case of ectopic pancreas located in the Meckel's diverticulum, resected at laparotomy performed for colonic disease. Although in retrospective review symptoms from ectopic pancreas are reported in up to 50% of the cases our patient was free of symptoms. In addition the finding of ectopic pancreas in Meckel's diverticulum has been described only seldom in the previous literature. Treatment however should always be resection in order to prevent complications that may occur, although rarely.

[Proctological surgery in the one-day surgery regimen: the preliminary results with 232 patients]. / Chirurgia proctologica in regime di one day surgery: risultati preliminari su 232 pazienti.

Simple anorectal surgery can be routinely employed on a one-day surgery (ODS) bases; however complications such as bleeding, urinary retention, and postoperative pain represent a limitation in this respect. In this paper we report preliminary results of our experience in surgery for haemorrhoids, anal fissures and fistulas, achieved in two years on 232 patients. Our protocol includes admission in the morning of the operation and preoperative evaluation by means of ECG, coagulation profile, assay of beta-HCG for female patients. The patients, prepared with a self-administered enema and perianal applications of prilocaine-lidocaine ointment, is taken in the operative room were a venous line is placed and an anaesthesiologist proceed to monitoring of ECG, blood pressure and oximetry. 211 patients were operated under locoregional anaesthesia performed by the surgeon by means of bilateral pudendal nerves blocking. Whereas the remaining underwent general or spinal anesthesia. With this approach we performed 106 haemorrhoidectomies, 96 sphincterotomies, 19 of which with posterior anoplasty and 30 fistulectomy or fistulotomy. 60 mg of ketorolac have been injected locally at the end of operation in order to improve postoperative pain control. Patients undergoing hemorrhoidectomy, anoplasty, fistulotomy or fistulectomy were discharged after 24 hours whereas those undergoing sphincterotomy went home the same day. We reported 4 early postoperative complications in the haemorrhoids group with an incidence of 1.7% (two bleedings, one urinary retention and one fever) treated conservatively. Postoperative pain resulted adequately controlled by a low dosage of NSAID (a mean of 3.7 doses of 30 mg ketorolac/patient). Our satisfactory results seem to suggest continuing the practice of one-day surgery in proctology.

[The use of prosthetic meshes in the surgical treatment of inguinal hernia: the costs and profits for the local health screening unit]. / Utilizzazione delle reti protesiche nel trattamento chirurgico dell'ernia inguinale: costi e guadagni per la ULSS.

BACKGROUND: Inguinal hernioplasty represents one of the most frequently performed surgical operation. The recent introduction of prosthetic mesh made Bassini operation obsolete, with more space gained by the newly developed "tension-free" and "sutureless" surgical techniques. This new approach, however, results in increased initial costs for the hospital, due to the purchase of mesh materials. On the other hand a reduction of overall expenses for a single hernia repair should be expected. In this work an attempt is made to verify this, by calculating the cost-benefit ratio of different techniques for hernia repair. METHODS: The type and amount of materials used in a standard Bassini hernia repair, Lichtenstein and Trabucco have been examined. The amount of anesthetic drugs required, the average hospital stay and time away from work were recorded too. The costs of the three operations considered, not including routine expenses (operating room, bed sheet, etc.) have been estimated. RESULTS: Lichtenstein and Trabucco repair performed in local anesthesia (L. 1.354.120, L. 1.567.120) were cheaper than Bassini (L. 2.820.950). CONCLUSIONS: Since the system of diagnosis-related group offers a fixed amount of reimbursement for hernia repair (L. 3.247.000), the extensive use of tension free and sutureless methods, offers better profit for the Hospital. Last but not least, tension free hernia repair ensures short hospital stay, less postoperative pain, good compliance and better quality of life for the patient.

[The influence of laparoscopic cholecystectomy vs laparotomy on the monocyte antigen expression (HLA-DR)]. / L'influenza della colecistectomia laparoscopica versus laparatomica sull'antigene di espressione dei monociti (HLA-DR).

It is well known that surgery significantly decrenses immune responses. Laparoscopic cholecystectomy (LC) is a so called "mini invasive" surgical presidia, and on the basis of this consideration we have investigated if and how the immune response is modified in patients after laparoscopic cholecystectomy compare to patients undergone open cholecystectomy. Immune-activity (neutrophils, total lymfocytes count, lymphocytes subpopulations, HLA-DR) was evaluated in 53 patients one day before surgery and p.o. after 1. 3 and 6 days; 26 patients underwent "open" cholecystectomy and 27 LC. One day after surgery patients with open cholecystectomy showed significant increase (p < = 0.05) of plasma neutrophils, while these parameters were almost unchanged in patients with L.C. Finally monocyte antigen HLA-DR was also reduced in patients with "open" cholecystectomy: in this group we also recorded 2 cases (7.6%) of respiratory tract infection. In conclusion LC, strongly reduces p.o. pain, hospitalization, promotes earlier recovery and return to normal activity, avoiding p.o. immunosuppression, mostly due to conservation of HLA-DR activity, with better p.o. morbidity compare to open surgery.

[Intestinal obstruction caused by ischemic colitis: description of 3 surgically treated cases]. / Occlusione intestinale da colite ischemica: descrizione di 3 casi trattati chirurgicamente.

The diagnosis of ischemic colitis is challenging and still based upon a high index of suspicion. We report here, three patients affected by ischemic colitis causing stenosis and intestinal obstruction who required surgical treatment. Results of surgery in the three cases were not fair reflecting the high mortality and morbidity rate of ischemic colitis. However, the three cases showed peculiar features allowing us to make a few speculative considerations. Better results in the treatment of ischemic colitis might be achieved by means of a prompt recognition of the initial picture and through a better control of the many associated diseases, that represent the main risk factor for the development of ischemic colitis itself and for the bad prognosis of surgical treatment.

Bowel stricture due to ischemic colitis: report of three cases requiring surgery.

The diagnosis of ischemic colitis is challenging and still based upon a high index of suspicion. We report here, three patients affected by ischemic colitis causing stenosis and intestinal obstruction that required surgical treatment. Results of surgery in the three cases were not fair reflecting the high mortality and morbidity rate of ischemic colitis. However, the three cases showed peculiar features allowing us to make a few speculative considerations. Better results in the treatment of ischemic colitis might be achieved by means of a prompt recognition of the initial picture and through a better control of the many associated diseases, that represent the main risk factor for the development of ischemic colitis itself and for the bad prognosis of surgical treatment.