Lorenzo Cattorini

Fibrin glue in the treatment of anal fistula: a systematic review.

BackgroundNew sphincter-saving approaches have been applied in the treatment of perianal fistula in order to avoid the risk of fecal incontinence. Among them, the fibrin glue technique is popular because of its simplicity and repeatability. The aim of this review is to compare the fibrin glue application to surgery alone, considering the healing and complication rates.MethodsWe performed a systematic review searching for published randomized and controlled clinical trials without any language restriction by using electronic databases. All these studies were assessed as to whether they compared conventional surgical treatment versus fibrin glue treatment in patients with anal fistulas, in order to establish both the efficacy and safety of each treatment. We used Review Manager 5 to conduct the review.ResultsThe healing rate is higher in those patients who underwent the conventional surgical treatment (P = 0,68), although the treatment with fibrin glue gives no evidence of anal incontinence (P = 0,08). Furthermore two subgroup analyses were performed: fibrin glue in combination with intra-adhesive antibiotics versus fibrin glue alone and anal fistula plug versus fibrin glue. In the first subgroup there were not differences in healing (P = 0,65). Whereas in the second subgroup analysis the healing rate is statistically significant for the patients who underwent the anal fistula plug treatment instead of the fibrin glue treatment (P = 0,02).ConclusionIn literature there are only two randomized controlled trials comparing the conventional surgical management versus the fibrin glue treatment in patients with anal fistulas. Although from our statistical analysis we cannot find any statistically significant result, the healing rate remains higher in patients who underwent the conventional surgical treatment (P = 0,68), and the anal incontinence rate is very low in the fibrin glue treatment group (P = 0,08). Anyway the limited collected data do not support the use of fibrin glue. Moreover, in our subgroup analysis the use of fibrin glue in combination with intra-adhesive antibiotics does not improve the healing rate (P = 0.65), whereas the anal fistula plug treatment compared to the fibrin glue treatment shows good results (P = 0,02), although the poor number of patients treated does not lead to any statistically evident conclusion. This systematic review underlines the need of new RCTs upon this issue.

Ovarian hydatid cyst: A case report

Discovering an hydatid cyst in pelvic region, especially as primary localization, is a rare event; as a matter of fact according to data provided by literature the incidence is between 0.2 and 2.25%. The ovarian involvement is often secondary to a cysts dissemination localized in a different site. When possible the optimal treatment is represented by radical laparotomic cystectomy. We report a case of an old woman affected by this pathology that we have treated with a cysts marsupialization after a draining and irrigation of cyst cavity with hypertonic saline solutions.

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.

Recurrent differentiated thyroid cancer: to cut or burn

The term “relapse carcinoma” is used improperly to indicate either a local or loco-regional relapse or a systematic metastatsis [1]. Local relapse (LR) after thyroidectomy for cancer is “the repetition of the neoplastic lesion in proximity of the previous intervention of excision” [2]. According to Duren [3] relapses of thyroidal carcinoma need to be classified as: local (LR): that may present itself in the residual thyroid lobe or in the thyroid bed where surgery was performed; loco-regional (RLR): that may present in the cervical lymph nodes of the central compartment or lateral-cervical nodes; and metastasis in distance (MD). The MD are frequently synchronous with LR or RLR; they have haematogenous genesis and concern most frequently the lungs and skeleton. There is controversy over how to catergorize the relapse in the thyroidal bed with infiltrations of neighbouring organs (periodontal structures muscles, thyroidal cartilage, cricoid, laryngeal nerves, etc. and the neighbouring organs oesophagus, trachea, larynx). As per the classification proposed by Duren [3] these should be considered as LR, whereas according to Mozzillo and Pezzullo [1] they are categorised as RLR. The RLR at the level of the cervical lymphnodal stations represents an ulterior problem: are these true relapses, residual cancer, or recurrence in progression? Caraco [4], in his report to the ninety-fourth Congress of the Italian Society of Surgery, specified that local recurrences are only those recurrences that are characterized by the appearance of neoplastic tissue in the thyroidal lodge, in the residual parenchyma, and in the adjacent structures, excluding the lymph nodes [5,6]. In nearly 53% of cases the relapse is reported in RLR, in 28% in LR, and in 13% the MD is present of these 6% of cases have mixed relapses [7]; the prognosis of LR is however, better than that of the others [8]. The differentiated tumors of the thyroid are slow growing and due to this rarely reach notable dimensions or result in metastasis in lymph and/or haematic systems [2]. Only 10% of patients die from differentiated thyroid cancer [9]. Most of the local relapses occur within the first five years of the excision of the primary cancer [5,6,10-12], however, the recurrence can occur as late as 20 years after the initial diagnosis and treatment [13]. An accurate evaluation of incidence of LR is possible solely with a considerable number of treated patients and lengthy follow-up that is not available at most centres and hence this kind of information can be obtained from the date from centres that have high volume of thyroid carcinoma and good follow-up like Mayo Clinic or Lahey Clinic [5,6,13] or through observational studies at several other medical centres [14]. Currently relapses represent a rare event in patients who undergo removal of thyroidal carcinoma (3-13%) [5,6,10-12,15-17]. This is due to the ever increasing frequency of total thyroidectomy for management of cancer [18]. The complete excision of the thyroidal parenchyma prevents local recurrence. Giovanni Razzaboni in “Treatise on Prognostic Surgery” (1938) stated that “The most rational operating method, so long as not free from grave consequences of another kind, remains the total extra-capsular thyroidectomy, so as is used, when possible, for the surgical removal of whatever other tumour” [19]. he further emphasized in his work published after his death in 1956 entitled “Treatise on Clinical Therapeutic Surgery” that “Only an removal of this capacity justifies, in the face of a proven malignant tumour, surgical intervention, any other incomplete or partial demolition does nothing but accelerate the ready reoccurrences, even in a very short time” [20]. * Correspondence: cirocchiroberto@yahoo.it General and Emergency Surgical Unit. Department of Surgical Sciences, Radiology and Dentistry. University of Perugia, Perugia, Italy Full list of author information is available at the end of the article Cirocchi et al. World Journal of Surgical Oncology 2011, 9:89 http://www.wjso.com/content/9/1/89 WORLD JOURNAL OF SURGICAL ONCOLOGY

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.

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.