Pietro Renzulli

Ulcerative colitis : correlation of the Rachmilewitz endoscopic activity index with fecal calprotectin, clinical activity, C-reactive protein, and blood leukocytes

Background: The accuracy of noninvasive markers for the detection of endoscopically active ulcerative colitis (UC) according the Rachmilewitz Score is so far unknown. The aim was to evaluate the correlation between endoscopic disease activity and fecal calprotectin, Clinical Activity Index, C‐reactive protein (CRP), and blood leukocytes. Methods: UC patients undergoing colonoscopy were prospectively enrolled and scored independently according the endoscopic and clinical part of the Rachmilewitz Index. Patients and controls provided fecal and blood samples for measuring calprotectin, CRP, and leukocytes. Results: Values in UC patients (n = 134) compared to controls (n = 48): calprotectin: 396 ± 351 versus 18.1 ± 5 μg/g, CRP 16 ± 13 versus 3 ± 2 mg/L, blood leukocytes 9.9 ± 3.5 versus 5.4 ± 1.9 g/L (all P < 0.001). Endoscopic disease activity correlated closest with calprotectin (Spearmans rank correlation coefficient r = 0.834), followed by Clinical Activity Index (r = 0.672), CRP (r = 0.503), and leukocytes (r = 0.461). Calprotectin levels were significantly lower in UC patients with inactive disease (endoscopic score 0‐3, calprotectin 42 ± 38 μg/g), compared to patients with mild (score 4‐6, calprotectin 210 ± 121 μg/g, P < 0.001), moderate (score 7‐9, calprotectin 392 ± 246 μg/g, P = 0.002), and severe disease (score 10‐12, calprotectin 730 ± 291 μg/g, P < 0.001). The overall accuracy for the detection of endoscopically active disease (score ≥4) was 89% for calprotectin, 73% for Clinical Activity Index, 62% for elevated CRP, and 60% for leukocytosis. Conclusions: Fecal calprotectin correlated closest with endoscopic disease activity, followed by Clinical Activity Index, CRP, and blood leukocytes. Furthermore, fecal calprotectin was the only marker that reliably discriminated inactive from mild, moderate, and highly active disease, which emphasizes its usefulness for activity monitoring. Inflamm Bowel Dis 2009

Systematic review of atraumatic splenic rupture.

Atraumatic splenic rupture (ASR) is an ill defined clinicopathological entity.

Use of accurate diagnostic criteria may increase incidence of stercoral perforation of the colon

PURPOSE: Stercoral perforation of the colon is reported to be a rare disease with poor prognosis. The aim of this study was to determine the frequency of stercoral perforation of the colon, to define diagnostic criteria for stercoral perforation of the colon, and to analyze the patient outcome in a university hospital gastrointestinal surgery unit. METHODS: From November 1993 until November 1998 all surgically treated patients with a colorectal disease were prospectively recorded in a computerized database. Diagnosis of stercoral perforation of the colon was made if 1) the colonic perforation was round or ovoid, exceeded 1 cm in diameter, and lay antimesenteric; 2) fecalomas were present within the colon, protruding through the perforation site or lying within the abdominal cavity; and 3) pressure necrosis or ulcer and chronic inflammatory reaction around the perforation site were present microscopically. Any additional colon pathology led to exclusion from the diagnosis of stercoral perforation of the colon. Using the same criteria, 81 cases in the literature were found to qualify and were further analyzed. RESULTS: In a five-year period 1,295 patients underwent colorectal interventions through laparotomy. A total of 566 (44 percent) cases were emergencies, 220 (17 percent) of these caused by colonic perforation. Seven patients had stercoral perforation of the colon. The incidence of stercoral perforation of the colon was 0.5 percent of all surgical colorectal procedures through laparotomy, 1.2 percent of all emergency colorectal procedures, and 3.2 percent of all colonic perforations. The mean age of the patients was 59 (median, 64; range, 22–85) years. All perforations were situated in the left hemicolon or upper rectum. The round or ovoid perforation had a mean diameter of 3.6 cm. Fecalomas were present in all patients and protruded from the perforation site or were found within the free abdominal cavity in three of them. Generalized stercoral peritonitis was a constant finding. Using a colonic resection without immediate restoration of continuity, an extensive intraoperative lavage, and antibiotics, there was no in-hospital mortality. Analysis of the reports in the literature revealed additionally that 28 percent of patients with stercoral perforation of the colon have multiple stercoral ulcers in the colon and that substantial mortality is encountered if only minor surgical procedures of treatment are used. CONCLUSIONS: The incidence of stercoral perforation of the colon seemed to have been underestimated. The reason for this might be the lack of defined diagnostic criteria for this disease. Low mortality is obtained by early surgical eradication of the affected part of the colon, including all stercoral ulcers, and by aggressive therapy for peritonitis.

Preoperative Colonoscopic Derotation Is Beneficial in Acute Colonic Volvulus

Aims: Analysis of preoperative and operative management of acute colonic volvulus and development of treatment guidelines in a region of low incidence. Methods: A study of 42 consecutive patients operated for acute colonic volvulus between 1970 and 2000. Results: There were 20 patients with sigmoid volvulus, 21 with cecal volvulus and 1 with volvulus of the transverse colon. All patients presented as emergencies. The correct preoperative diagnosis was possible for sigmoid volvulus in 95% (19/20) of cases and for cecal volvulus in 67% (14/21). Preoperative colonoscopic volvulus derotation was attempted in 19 patients and successfully completed in 9 patients (47%). The success rates for preoperative colonoscopic derotation were 58 (7/12) and 33% (2/6) for sigmoid and cecal volvulus, respectively. Thirty-four patients (81%) underwent colon resections, 26 times as a single-stage procedure, and 8 patients (19%) underwent non-resectional operative techniques. Overall surgical morbidity was 24%, the reoperation rate 9.5% and mortality 12% (5/42). The subgroup of 9 patients with successful non-operative volvulus derotation, however, underwent semi-elective single-stage colonic resection without surgical morbidity or mortality. There were no recurrences during a median follow-up period of 9.5 years. Conclusion: In the absence of clinical, laboratory or radiological signs of bowel necrosis or perforation, colonoscopic volvulus derotation is recommended in all cases of acute colonic volvulus, followed by semi-elective single-stage colonic resection.

Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach

BACKGROUND Once paraesophageal hernia has been diagnosed, it should be repaired immediately because of life-threatening complications such as bleeding, ischemia, and perforation when intrathoracic strangulation or volvulus occurs. We describe our surgical strategy for treating this rare type of hiatal hernia with regard to early and late postoperative complications. STUDY DESIGN This was a retrospective case series from a university hospital. Twelve patients (seven women and five men) with a mean age of 64 years (range, 50-76 years) and a completely intrathoracic stomach underwent laparoscopic paraesophageal hernia repair. Seven patients had a type 2 hernia, and five patients had a type 3 hernia. Additional organoaxial volvulus was present in three patients. All patients underwent reduction of the stomach and the greater omentum, excision of the hernia sac, closure of the hiatal defect, and a floppy Nissen fundoplication. RESULTS Because of severe adhesions, one patient needed an open stomach reduction (conversion rate, 8%). The mean operating time was 161 minutes (range, 110-200 minutes), blood loss was minimal, and the mean postoperative hospital stay was 6 days (range, 4-7 days). There were no intraoperative complications, but early postoperative complications occurred in three patients (25%; one with dysphagia, 1 reoperation due to organoaxial gastric rotation with gastroduodenal obstruction, and one with deep venous thrombosis). No deaths occurred. Followup in all patients is complete, with a mean followup time of 21 months (range, 3-40 months). The complication rate after long-term followup was 8%, and reflux esophagitis symptoms in one patient were completely relieved by medical therapy. CONCLUSIONS Laparoscopic paraesophageal hernia repair was feasible and safe with low morbidity and mortality rates in this elderly patient group. To achieve good long-term results, standard surgical treatment should include reduction of the stomach, complete excision of the hernia sac, closure of the hiatal defect, floppy Nissen fundoplication, and anterior gastropexy.

Management of blunt injuries to the spleen

Non‐operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM.

Severe acute pancreatitis: Case-oriented discussion of interdisciplinary management

The clinical course of an episode of acute pancreatitis varies from a mild, transitory illness to a severe often necrotizing form with distant organ failure and a mortality rate of 20–40%. Patients with severe pancreatitis, representing about 15–20% of all patients with acute pancreatitis, need to be identified as early as possible after onset of symptoms allowing starting intensive care treatment early in the disease process. An episode of severe acute pancreatitis progresses in two phases. The first 10–14 days are characterized by a systemic inflammatory response syndrome maintained by the release of various inflammatory mediators. The second phase, beginning about 10–14 days after the onset of the disease is dominated by sepsis-related morbidity due to infected peripancreatic and pancreatic necrosis. This state is associated with septic multiple organ systemic failure. The importance of infection on the outcome of necrotizing pancreatitis has been clearly delineated and the pre-emptive use of broad-spectrum antibiotics that achieve effective tissue concentrations is considered standard management of patients with severe necrotizing pancreatitis, especially if associated with organ failure or extended necrosis. Patients with infected necrosis should undergo a surgical intervention. The standard open technique consisting of an organ preserving necrosectomy followed by a postoperative concept of lavage and/or drainage to evacuate necrotic debris occurring during the further course has recently been challenged by various minimally invasive approaches.

Low-grade endometrial stromal sarcoma with inferior vena cava tumor thrombus and intracardiac extension: Radical resection may improve recurrence free survival

BACKGROUND Endometrial stromal sarcoma (ESS) represents 0.2% of all uterine malignancies. Based on the mitotic activity, a distinction is made between low and high-grade ESS. Although the overall five-year survival rate for low-grade ESS exceeds 80%, about 50% of the patients show tumor recurrence, mostly after a long latency period. Tumor invasion of the great vessels is extremely rare. We describe a patient with advanced low-grade ESS with tumor invasion of the infrarenal aorta and the inferior vena cava. The patient presented with a large tumor thrombus extending from the inferior vena cava into the right atrium. METHODS Review of literature and identification of 19 patients, including our own case report, with advanced low-grade ESS with invasion of the great vessels and formation of an inferior vena cava tumor thrombus. RESULTS All 19 patients presented with an abdominal tumor mass and a tumor thrombus protruding into the inferior vena cava. The tumor thrombus extended into the right heart cavities in nine patients reaching the right atrium in four, the right ventricle in three and the pulmonary artery in two patients. There were 5 patients with an advanced primary tumor and 14 patients with an advanced recurrent tumor. Seven patients presented with synchronous metastatic disease and six patients with a pelvic tumor infiltrating the bladder, the rectosigmoid colon or the infrarenal aorta. Mean age at surgery was 45.9+/-12.3 years (median 47, range 25-65 years). Tumor thrombectomy was accomplished by cavatomy or by right atriotomy after installation of a cardiopulmonary bypass. There was no peri-operative mortality and a very low morbidity. Radical tumor resections were achieved in 10 patients. The follow-up for these 10 patients was 2+/-1.3 years (median 2, range 0.3-4.5 years). Nine patients remained recurrence free whereas one patient suffered an asymptomatic local recurrence. CONCLUSIONS Low-grade ESS is a rare angioinvasive tumor with a high recurrence rate. Resection of an inferior vena cava tumor thrombus, even with extension into the right heart cavities, can be performed safely. Extensive radical surgery is therefore justified in the treatment of advanced tumor manifestations of a low-grade ESS potentially improving recurrence free survival.

Colon interposition for esophageal replacement: a single-center experience.

BackgroundGastric tube interposition has become the method of choice for esophageal replacement after esophagectomy. Colon interposition, on the other hand, is widely considered to be a method of last resort, associated with high morbidity and mortality. The present study reviews our experience with colon interposition for esophageal replacement.PatientsNineteen consecutive patients undergoing colon interposition for esophageal replacement between 1 January 1994 and 31 July 2001 were reviewed. Outcome was compared with international publications on colon interposition as well as with our results following gastric tube interposition (fundus rotation gastroplasty).ResultsFourteen men and five women with a median age of 68 years (range 44–78) underwent colon interposition for benign (n=9) and malignant (n=10) lesions. Eighteen patients underwent trans-hiatal esophagectomy with cervical anastomosis, and one patient underwent thoraco-abdominal esophagectomy with intrathoracic anastomosis. Surgical morbidity was 36.8% (7/19). Anastomotic insufficiency and fatal mediastinal bleeding occurred in one patient each (5.3%). No cases of graft necrosis were observed, and no re-operations were necessary. In-hospital mortality was 15.8% (3/19), twice due to surgical complications (abdominal sepsis, mediastinal bleeding) and once due to pulmonary and cardiac failure. As a late complication, four patients (21.1%) developed anastomotic strictures that necessitated repeated endoscopic dilatation.ConclusionsGastric tube interposition remains the method of choice for esophageal replacement. Colon interposition, however, is a valuable alternative with a good long-term function. Early mortality, however, remains a matter of serious concern.

Long-term follow up (37–69 years) of patients with bladder exstrophy treated with ureterosigmoidostomy: Uro-nephrological outcome

OBJECTIVE To describe the urological and nephrological long-term outcome of patients born with classical bladder exstrophy treated with bilateral ureterosigmoidostomies in early childhood. PATIENTS AND METHOD Out of 42 patients born with bladder exstrophy in Switzerland between 1937 and 1968, 25 participated in this study; seven had died, seven were lost to follow up and three refused consent. Assessment included chart review, clinical examination, and assessment of renal function and morphology. RESULTS After a follow-up period of 37-69 years ((mean 50 years), 13 of the 25 participants (52%) had their ureterosigmoidostomy still in place. All others had different forms of urinary diversions. Fifteen (60%) patients had normal renal function or mild chronic kidney disease as assessed by estimated glomerular filtration rate. Three patients were on renal replacement therapy. MRI (n=16) showed 10 morphologically normal kidneys. One patient suffered from adenocarcinoma of the colon, five had benign colonic polyps, one urethral papillary carcinoma and 18 no evidence of tumor. CONCLUSION The majority of our patients have normal or mildly impaired renal function and a well functioning ureterosigmoidostomy. This is remarkable, given the fact that ureterosigmoidostomies are considered to be refluxing high-pressure reservoirs at risk of renal injury and malignancy.