Alessandro Spizzirri

The sigmoid volvulus: surgical timing and mortality for different clinical types

BackgroundIn western countries intestinal obstruction caused by sigmoid volvulus is rare and its mortality remains significant in patients with late diagnosis. The aim of this work is to assess what is the correct surgical timing and how the prognosis changes for the different clinical types.MethodsWe realized a retrospective clinical study including all the patients treated for sigmoid volvulus in the Department of General Surgery, St Maria Hospital, Terni, from January 1996 till January 2009. We selected 23 patients and divided them in 2 groups on the basis of the clinical onset: patients with clear clinical signs of obstruction and patients with subocclusive symptoms. We focused on 30-day postoperative mortality in relation to the surgical timing and procedure performed for each group.ResultsIn the obstruction group mortality rate was 44% and it concerned only the patients who had clinical signs and symptoms of peritonitis and that were treated with a sigmoid resection (57%). Conversely none of the patients treated with intestinal derotation and colopexy died. In the subocclusive group mortality was 35% and it increased up to 50% in those patients with a late diagnosis who underwent a sigmoid resection.ConclusionsThe mortality of patients affected by sigmoid volvulus is related to the disease stage, prompt surgical timing, functional status of the patient and his collaboration with the clinicians in the pre-operative decision making process. Mortality is higher in both obstructed patients with generalized peritonitis and patients affected by subocclusion with late diagnosis and surgical treatment; in both scenarios a Hartmanns procedure is the proper operation to be considered.

Virtual colonoscopy in stenosing colorectal cancer

BackgroundBetween 5 and 10% of the patients undergoing a colonoscopy cannot have a complete procedure mainly due to stenosing neoplastic lesion of rectum or distal colon. Nevertheless the elective surgical treatment concerning the stenosis is to be performed after the pre-operative assessment of the colonic segments upstream the cancer.The aim of this study is to illustrate our experience with the Computed Tomographic Colonography (CTC) for the pre-operative assessment of the entire colon in the patients with stenosing colorectal cancers.MethodsFrom January 2005 till March 2009, we observed and treated surgically 43 patients with stenosing colorectal neoplastic lesions. All patients did not tolerate the pre-operative colonoscopy. For this reason they underwent a pre-operative CTC in order to have a complete assessment of the entire colon. All patients underwent a follow-up colonoscopy 3 months after the surgical treatment. The CTC results were compared with both macroscopic examination of the specimen and the follow-up coloscopy.ResultsThe pre-operative CTC showed four synchronous lesions in four patients (9.3% of the cases). The macroscopic examination of the specimen revealed three small sessile polyps (3 - 4 mm in diameter) missed in the pre-operative assessment near the stenosing colorectal cancer. The follow-up colonoscopy showed four additional sessile polyps with a diameter between 3 - 11 mm in three patients.Our experience shows that CTC has a sensitivity of 83,7%.ConclusionIn patients with stenosing colonic lesions, CTC allows to assess the entire colon pre-operatively avoiding the need of an intraoperative colonoscopy. More synchronous lesions are detected and treated at the time of the elective surgery for the stenosing cancer avoiding further surgery later on.

A severe case of hemobilia and biliary fistula following an open urgent cholecystectomy

BackgroundCholecystectomy has been the treatment of choice for symptomatic gallstones, but remains the greatest source of post-operative biliary injuries. Laparoscopic approach has been recently preferred because of short hospitalisation and low morbidity but has an higher incidence of biliary leakages and bile duct injuries than open one due to a technical error or misinterpretation of the anatomy. Even open cholecystectomy presents a small number of complications especially if it was performed in urgency. Hemobilia is one of the most common cause of upper gastrointestinal bleeding from the biliary ducts into the gastrointestinal tract due to trauma, advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage.MethodsWe report here a case of massive hemobilia in a 60-year-old man who underwent an urgent open cholecystectomy and a subsequent placement of a transhepatic biliary drainage.ConclusionThe management of these complications enclose endoscopic, percutaneous and surgical therapies. After a diagnosis of biliary fistula, its most important to assess the adequacy of bile drainage to determine a controlled fistula and to avoid bile collection and peritonitis. Transarterial embolization is the first line of intervention to stop hemobilia while surgical intervention should be considered if embolization fails or is contraindicated.

Emergency treatment of complicated incisional hernias: a case study

BackgroundThe emergency treatment of incisional hernias is infrequent but it can be complicated with strangulation or obstruction and in some cases the surgical approach may also include an intestinal resection with the possibility of peritoneal contamination. Our study aims at reporting our experience in the emergency treatment of complicated incisional hernias.MethodsSince January 1999 till July 2008, 89 patients (55 males and 34 females) were treated for complicated incisional hernias in emergency. The patients were divided in two groups: Group I consisting of 33 patients that were treated with prosthesis apposition and Group II, consisting of 56 patients that were treated by performing a direct abdominal wall muscles suture.ResultsAll the patients underwent a 6-month follow up; we noticed 9 recurrences (9/56, 16%) in the patients treated with direct abdominal wall muscles suture and 1 recurrence (1/33, 3%) in the group of patients treated with the prosthesis apposition.ConclusionsAccording to our experience, the emergency treatment of complicated incisional hernias through prosthesis apposition is always feasible and ensures less post-operative complications (16% vs 21,2%) and recurrences (3% vs 16%) compared to the patients treated with direct muscular suture.

Acute pancreatitis in the elderly: our experience.

The aim of the trial is to evaluate etiology, clinical characteristics and treatment of acute pancreatitis in elderly patients.

pT2 report after transanal endoscopic microsurgery excision in elderly patient T1 staged: a case report

Materials and methods We present a case of rectorrhagia in an 83-years old patient. On rectal exploration a little hard lesion was found. A colonoscopy with biopsy was performed to search for synchronous lesions. A virtual colonoscopy and CT total body were performed to stage the patient and integrate the endoscopy and they both were negative. The endoscopy confirmed the lesion (adenocarcinoma G2) and described it as sessile, with a diameter of 22 mm, in the right wall of the middle rectum. A transanal ultrasonography was performed and staged the lesion as T1, N0. The hematological investigations showed lymphocytosis in relation with an anamnestic LLC, tumor markers (CEA, Ca 19.9) were in normal range. Considering stage (T1, N0, M0), age and clinical status, the decision of performing TEM was taken. The cancer was completely removed and sent for histological examination.

Carcinoid and hypocoagulation state in geriatric patients: a rare case

Materials and methods We observed a 79-year-old patient suffering from high blood pressure and Alzheimer, with an history of periodic abdominal pain from almost 2 months and 10 Kg weight loss in the last month. In suspicious of a carcinoid, the patient underwent scintigraphy with In-111 showing the presence of two abnormal focal buildup of the trace compatible with the presence of a productive tissue with somatostatin receptors. Lab exams were normal, except for the serum Chromogranin A (42.0 U/l), the 5 OH indole acetic acid (11.0 mg/24 h) and the urinary VanillylMandelic acid (7.0 mg/24 h). Therefore the patient underwent surgery. The patient had a regular course until the third post-operative day when an acute anemia appeared (GR 2460000, Hb 7.0 g/dl, HCT 22.3%). Therefore we performed an emergency intervention that showed the presence of diffuse bleeding from the parietal and visceral peritoneum with haemorragic filling of the transverse mesocolon. Results The association between carcinoid and hypocoagulative state is rare and their connection is not yet clear.

Biliary fistula following open colecystectomy: report of a case and review of literature

Materials and methods A 73-year-old man came to our observation with pain to upper quadrants of the abdomen, fever, signs of peritoneal involvement, leucocytosis, and the increment of cholestasis markers, while US scan showed an acute cholecystitis. The patient underwent a laparoscopic cholecystectomy (LC) but we converted the procedure. We positioned a T-tube and an abdominal drainage. Postoperative bilirubin level began to increase, the abdominal drainage began to drain bile despite the patients conditions were good. A parenteral nutrition was instituted, deficits of electrolytes and vitamins were corrected and octreotide was delivered. We decided to position a PTHBD on the right biliary emisystem and to perform ERCP to reconstruct biliary tract. Post-operative control showed a well-positioned drainage but a biliary leakage so we decided to perform a hepaticojejunostomy. During the 9th day after hepaticojejunostomy the patient developed a severe episode of hemobilia due to a big pseudoaneurysm on the right hepatic artery, which was covered by stenting. After that general conditions of the patient improved day by day and was discharged after 48 days. Results In the case above, conservative treatment had been made immediately because spontaneous closure of the fistula is often usual. Endoscopic treatment of fistula by sphincterotomy, stenting or both is indicated in most patients. Operation is indicated when non-operative measures are not suitable, such as in patients with diffuse bile peritonitis. The increased use of interventional procedures is associated with an increased incidence of vascular injuries and hemobilia. Angiography could detect significant hemobilia in over 90% of patients, and allow the localization of vascular lesions and therapeutic embolization.

Presacral myelolipoma in a geriatric patient

Background Presacral tumors are most frequently benign, occasionally malignant with a slow growth. Their incidence is 1:40000 and they are asymptomatic in the 26–50% of cases. When visible symptoms occur, these are related to the dimensions of the tumor, to its location and to the presence of infection. We believe all presacral tumors should undergo a surgical resection, even if the patient is asymptomatic and these are more frequently benign tumors.