Search

Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients’ conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann’s procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann’s procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.

To evaluate the efficacy of the damage control approach by two-step surgical procedure in not critical patients (without sepsis or septic shock) with peritonitis from limited acute mesenteric ischemia. From April 2013 to April 2020, 85 patients [49 (57.7%) women and 36 (42.3%) men, median age 69.5 (range 38-92)] were enrolled in this study and underwent emergency surgery. After resection of ischemic bowel, basing on the individual decision of the single surgeon, the patients underwent primary end-to-end anastomosis (Group 1) or damage control approach (Group 2) including primary laparotomy with resection of ischemic bowel, temporary abdominal closure and a second-look procedure at 48 h with re-evaluation of bowel vitality. Forty-seven (55.3%) patients underwent one-stage surgical treatment and 38 (44.7%) patients received a two-step procedure. In the latter group, at second exploration, 8 (21%) patients required a further intestinal resection, due to mesenteric ischemia progression. Both anastomosis dehiscence rate and need for ileostomy in Group 1 patients were significantly higher than in Group 2 (23.4% vs 5.3%: p = 0.03 and 19.1% vs 2.6%: p = 0.03; Fisher's exact test). No significative differences in mortality and morbidity rate were found between the two groups. The damage control approach by two-step surgical procedure may represent a valid innovative option in the management of not critical patients with limited acute mesenteric ischemia, achieving a better clinical outcome if compared with surgical treatment by one-step procedure.

The authors present a series of 15 patients with lower gastrointestinal bleeding. 11 (73%) out of 15 patients, were directly subjected to surgery, and 4 (37%) attempted to stop hemorrhage with angiography. In the group of patients undergoing surgery we had a mortality of 1 out of 12 (8%). In the group of patients undergoing embolization, two of four died with 50% of mortality. All patients undergoing surgery had received from a minimum of two to a maximum of four blood bags before surgery. 8 out of 12 patients (67%) received more than two bags. In 10 (67%) out of 15 patients TC scan preoperatively identified the site of bleeding. 10 cases out of 15 patients was evident Anticoagulant or antiplatelet use. In the group of patients undergoing surgical treatment with haemorrhage stopping 60% (6 out of 10) did not take these drugs. No patient had significant alterations to the INR value. Patients undergoing Surgical treatment without haemorrhage stopping had an average age significantly higher than the group with haemorrhage stopping (84 aa vs 54.2). In this group CT scan had identified the source of bleeding in one patient on two (50%) and all patients In the group of deceased patients, the average age was 78 aa, the tac had never identified the site of bleeding, and all had antiaggregates. In the group of deceased patients, the average age was 78 aa, CT scan had never identified the site of bleeding, and all In the group of deceased patients, the average age was 78 aa, the tac had never identified the site of bleeding, and all had antiaggregates KEY WORDS: Lower gastrointestinal bleeding, Prognostic factors, Surgical management.Gli autori presentano una serie di 15 pazienti affetti da emorragia digestiva. Su 15 pazienti, 11 (73%) sono stati sottoposti in prima istanza ad intervento chirurgico, e 4 (37%) a tentativo di arresto dell’ emorragia con procedura di embolizzazione. Nel gruppo pazienti sottoposti ad intervento chirurgico abbiamo avuto una mortalità di un 1 su 12 (8%). Nel gruppo dei pazienti sottoposti a tentativo di embolizzazione sono deceduti due su quattro con una mortalità del 50%. Tutti i pazienti sottoposti ad intervento chirurgico hanno ricevuto da un minimo di due ad un massimo di quattro unità di sangue prima dell’ intervento. 8 pazienti su 12 (il 67%) hanno ricevuto un numero di sacche superiore a due. La TAC ha identificato preoperatoriamente la sede del sanguinamento in 10 pazienti su 15 (67%). Su 15 pazienti, in 10 casi l’anamnesi ha evidenziato l’assunzione di antiagreganti. Nel gruppo dei pazienti sottoposti ad intervento considerato efficace ben il 60% (6 su 10) non assumevano tali farmaci. Nessun paziente presentava alterazioni significative dell’INR. I pazienti sottoposti ad intervento chirurgico considerato inefficace presentavano un età media significativamente superiore rispetto al gruppo considerato efficace 84 aa vs 54.2: la TAC aveva identificato la fonte del sanguinamento in un solo paziente su due (50%) e tutti assumevano antiaggreganti. Nel gruppo dei pazienti deceduti, l’età media era pari a 78 aa, la TAC non aveva identificato in nessun caso la sede del sanguinamento, e tutti assumevano antiaggreganti.

A 56 year-old man presented to the emergency department after a spontaneous bleeding of a giant mass located on the right axilla. Clinical diagnosis was recurrent hemorrhagic nodular melanoma. Ten months previously a malignant melanoma had been removed from the dorsum by radical excision and surgical margins had been disease-free (MM: Breslow IV, Clark IV, lung and lynphnode metastases). The patient required immediate emergency surgical intervention to prevent death by hemorrhagic shock. The tumor was bleeding and the patient required a transfusion. Subjective symptoms included pain in palpation and spontaneous hemorrhage, poor general appearance, pale skin, BP 80/40 mmHg, HR 100/min with overall symptoms of hypovolemic shock. At the time of surgery, radical tumor excision was performed with an approximately 3 cm circumferential gross tumor free margin. The resultant defect was reconstructed by pectoral rotation fascio-cutaneous flap. The histological diagnosis demonstrated an undifferentiated high-grade pleomorphic sarcoma with microscopic tumor free margins.Gli autori riportano il caso di un importante sanguinamento in un paziente di sesso maschile dell’età di 56 con una voluminosa neoformazione cutanea tra la regione ascellare e pettorale di destra. La presenza di una anamnesi positiva per escissione di melanoma cutaneo avanzato avvenuta otto mesi prima aveva fatto orientare inizialmente per una mestasi cutanea da melanoma. Invece l’esame istopatologico effettuato in seguito all’escissione chirurgica avvenuta in urgenza per sanguinamento attivo non controllabile con i comuni mezzi di emostasi ha dato luogo al riscontro di un voluminoso sarcoma bilobato dei tessuti molli. La continuità cutanea è stata ristabilita mediante lembo muscolare di rotazione. Il paziente è stato dimesso il decima giornata postoperatoria in via di guarigione ed affidato agli oncologi. Una accurata revisione della letteratura scientifica mostra come la contemporanea presenza di un melanoma cutaneo e di un sarcoma dei tessuti molli attivamente sanguinante sia un evenienza molto rara. Il trattamento chirurgico demolitivo resosi necessario per il controllo dell’emostasi si è mostrato essere efficace e ben tollerato da parte del paziente.

PURPOSE: This study was performed according to a prospective, randomized, open design. The aim was to test the efficacy of local application of nifedipine ointment in healing acute thrombosed external hemorrhoids. METHODS: Ninety-eight patients who gave their informed consent were recruited; they received clinical examination and anoscopy. A questionnaire to evaluate symptoms, pain, and concurrent use of analgesics was administered. Patients treated with nifedipine (n=50) used topical 0.3 percent nifedipine and 1.5 percent lidocaine ointment every 12 hours for two weeks. The control group, consisting of 48 patients, received topical 1.5 percent lidocaine ointment during therapy. RESULTS: Results obtained were as follows: complete relief of pain in 43 patients (86 percent) of the nifedipine-treated group as opposed to 24 patients (50 percent) of the control group after 7 days of therapy (P < 0.01); oral analgesics were used by 4 patients (8 percent) in the nifedipine-treated group as opposed to 26 patients (54.1 percent) of the control group after 7 days of therapy (P < 0.01); and resolution of acute thrombosed external hemorrhoids was achieved after 14 days of therapy in 46 patients (92 percent) of the nifedipine-treated group, as opposed to 22 patients (45.8 percent) of the control group (P < 0.01). We did not observe any systemic side effect in patients treated with nifedipine. CONCLUSIONS: Our study clearly demonstrates that the use of topical nifedipine, which at present is for treatment of cardiovascular disorders, is a reliable new option in the conservative treatment of thrombosed external hemorrhoids.

Laparoscopic procedures to treat colorectal cancer have been increasingly adopted in the last 15 years and seem to be well accepted by the patients. We studied 134 patients treated by laparoscopic colon resection, analysing the reasons for conversion to open laparotomy and outcomes. Over the period from July 2002 to January 2005, 134 patients with different colorectal cancers were treated with a laparoscopic approach in our department. We analysed the conversion rates and reasons for conversion, perioperative complications, hospital stay and recourse to blood transfusions. The laparoscopic procedures led to shorter hospitalisation and a reduction of the blood transfusion requirement, and were well accepted by the patients. The laparoscopic approach for malignant disease of the colon and rectum can improve many aspects of this treatment: Shorter hospitalisation, reduction of blood transfusions and a better quality of life. It also seems to lead to a lower non-specific depression of the immunological response. All these aspects may contribute to better treatment of patients with colorectal cancer. All kinds of laparoscopic colectomy can be performed with oncological criteria but the rate of conversion for rectal cancer is significantly higher (28.6%). In this study the complication rates in the laparoscopic colectomy and converted group were similar.

Intraoperative fine-needle aspiration cytology (IFNAC) of pancreatic lesions provides a safe method of rapid tissue diagnosis. Few studies have included a thorough statistical analysis of the factors influencing the diagnostic failure of IFNAC. IFNAC was performed on 196 patients during surgical procedures for pancreatic and periampullary masses over an 18-year period. The sensitivity was 90.6% and the specificity 100%. There was a 0% puncture-related complication rate. In all, 6 clinicopathological factors were analyzed to elucidate correlations, if any, with IFNAC failure using statistical analysis. Statistical analysis of each of these clinicopathological factor showed that the cases of failure tended to be related to small tumour size (P0.0001), well-differentiated grading (P0.002) and a nuclear size similar to the surrounding RBCs (P0.0001). Age, gender, moderately or poorly differentiated tumours, and multiple punctures proved to be of no statistical significance in our analysis. We suggest that diagnostic failure of IFNAC seems to be caused mainly by a structural factor such as tumour size and an intrinsic one (a cellular low atypism factor such as well-differentiated grading and small nuclear size). However, we would caution that negative IFNAC cannot be relied on to definitively exclude a diagnosis of carcinoma and, in many instances, the justification for pancreatic resection cannot always be based on cytologic findings, but rather on clinical and laparotomy findings.

PURPOSE: Chronic anal fissure may be treated by chemical or surgical sphincterotomy. The aim of this study was to test the efficacy of local application of nifedipine and lidocaine ointment in healing chronic anal fissure. METHODS: The study was performed according to a prospective, randomized, double-blind design. One hundred ten patients who gave informed consent were recruited. They received a clinical examination, a questionnaire to evaluate symptoms and pain, anorectal manometry, and anoscopy. Healing of anal fissure at Day 42 of therapy was defined as the primary efficacy variable of the study. Patients treated with nifedipine (n = 55) used topical 0.3 percent nifedipine and 1.5 percent lidocaine ointment every 12 hours for 6 weeks. The control group (n = 55) received topical 1.5 percent lidocaine and 1 percent hydrocortisone acetate ointment during therapy. Anal pressures were measured by recording resting and maximal voluntary contraction pressures at baseline and at Day 21. Long-term outcomes were determined after a median follow-up of 18 months. RESULTS: Healing of chronic anal fissure was achieved after 6 weeks of therapy in 94.5 percent of the nifedipine-treated patients (P < 0.001) as opposed to 16.4 percent of the controls. Mean anal resting pressure decreased from a mean value ± standard deviation of 47.2 ± 14.6 to 42 ± 12.4 mmHg in the nifedipine group. This represents a mean reduction of 11 percent (P = 0.002). Changes of maximal voluntary contraction in nifedipine-treated patients were not significant. No changes in mean anal resting pressure and maximal voluntary contraction were observed in the control group. We did not observe any systemic side effect in patients treated with nifedipine. After the blinding was removed, recurrence of the fissure was observed in 3 of 52 patients in the nifedipine group within 1 year of treatment, and 2 of these patients healed with an additional course of topical nifedipine and lidocaine ointment. CONCLUSIONS: Our study clearly demonstrates that the therapeutic use of topical nifedipine and lidocaine ointment should be extended to the conservative treatment of chronic anal fissure.

PURPOSE: This study was performed according to a prospective, randomized, double-blind, multicenter design. The aim was to test the efficacy of local application of nifedipine gela in healing acute anal fissure by relaxing the internal anal sphincter. METHODS: Two hundred eighty-three patients who gave informed consent were recruited; they received a clinical examination. A questionnaire to evaluate the symptoms and the pain was administered, and a proctoscopy and anorectal manometry were performed. Patients treated with nifedipine (n=141) used topical 0.2 percent nifedipine gel every 12 hours for three weeks. The control group, consisting of 142 patients, received topical 1 percent lidocaine and 1 percent hydrocortisone acetate gel during therapy. Manometry was performed before and on Days 14 and 21. Anal pressures were measured by recording resting and squeeze pressures. RESULTS: Results obtained were as follows: total remission from acute anal fissure was achieved after 21 days of therapy in 95 percent of the nifedipine-treated patients (P