Rosalia Patti

Tension-free hernia repair is associated with an increase in inflammatory response markers against the mesh ☆

BACKGROUND The purpose of this study was to evaluate the involvement of inflammatory mediators in patients undergoing Lichtenstein tension-free hernioplasty (LH) using polypropylene prosthetic materials or conventional Bassini hernia repair (BH). METHODS Thirty patients male with unilateral inguinal hernia without complications or recurrence were included in this study. Randomly, patients underwent LH or BH. Peripheral venous bloods samples were collected 24 hours prior to surgery and then 6, 24, 48 and 168 hours postoperatively. RESULTS We present evidences that LH patients showed a higher increased serum level of fibrinogen, C-reactive protein, alpha-1-antitrypsin, and interleukin-6 than BH patients. Postoperative visual analogue scales for pain were reduced on mobilization for patients undergoing LH compared with BH. Neutrophils were significantly increased only in LH compared with baseline. Ceruloplasmin, transferrin, and albumin levels were unmodified after BH or LH. CONCLUSIONS In conclusion our data show that although LH induces less pain and more rapid postoperative recovery, it is associated with an higher inflammatory response compared with BH, likely due to polypropylene mesh.

Improvement of wound healing after hemorrhoidectomy : A double-blind, randomized study of botulinum toxin injection

PURPOSEHemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of the internal sphincter seems to play an important role in the origin of pain. This study was designed to evaluate the effectiveness of intrasphincter injection of botulinum toxin after hemorrhoidectomy in reducing the maximum resting pressure of the anal canal, accelerating wound healing, and decreasing postoperative pain when resting and during defecation.METHODSThirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 30 days afterward in all patients undergoing Milligan-Morgan hemorrhoidectomy. One group received an injection of 0.4 ml of saline into the internal anal sphincter, the other group were injected with 0.4 ml of solution containing 20 units of botulinum toxin.RESULTSAfter five days from hemorrhoidectomy, maximum resting pressure decreased in the group injected with botulinum toxin and increased in the placebo group. The time of healing and postoperative pain when resting and during defecation significantly decreased in the group treated with an injection of botulinum toxin.CONCLUSIONSBotulinum toxin injection into internal anal sphincter after hemorrhoidectomy is effective in reducing maximum resting pressure, time of healing, and postoperative pain both on resting and during defecation in absence of complications or side effects.

Risk factors for postoperative delirium after colorectal surgery for carcinoma

BACKGROUND AND AIM Data regarding the incidence and risk factors for postoperative delirium (PD) after gastrointestinal surgery are heterogeneous because they include both benign and malignant disease. The aim of this study was to investigate the incidence and risk factors for PD in 100 consecutive patients over 65 years who underwent colorectal surgery for carcinoma. METHODS Pre-operative cognitive function was assessed using the Mini Mental State Examination. The onset of PD was diagnosed by the Confusion Assessment Methods administered to the patients every 12 h starting from the first postoperative day to discharge. The severity of PD was also evaluated with the Delirium Rating Scale. Different parameters: pre-, intra- and postoperative, were analyzed. Univariate and multivariate analyses were performed. RESULTS PD developed in 18% of patients. Univariate analysis revealed that advanced age, a history of PD, alcohol abuse, lower blood albumin concentration, intra-operative hypotension, elevated infusion volume and excessive blood loss were significantly related to the development of PD. On multivariate analysis, only lower levels of albumin, alcohol abuse, and hypotension were independent risk factors for PD. CONCLUSIONS These findings suggest that PD is a frequent complication after colorectal surgery for carcinoma. A model based on pre, intra and postoperative risk factors allows prediction of the patients risk for developing PD in order to implement preventive measures for this complication.

Cytokines and growth factors in wound drainage fluid from patients undergoing incisional hernia repair

Knowing the dynamics of growth factor and cytokine secretion within the site of a surgical operation is important, as they play a crucial role in the pathophysiology of wound healing and are a target for modifying the repair response. The aim of this study was to evaluate the production of several cytokines and growth factors in the drainage wound fluid from patients undergoing incisional hernia repair: namely, interleukin (IL)‐6, IL‐10, IL‐1α, IL‐1 ra, interferon‐γ, vascular endothelial growth factors and basic fibroblast growth factor. Ten female patients with abdominal midline incisional hernia undergoing surgical repair were included in this study. In all cases, a closed‐suction drain was inserted in the wound below the fascia and removed on postoperative day 4. Wound fluid was collected on postoperative days 1–4 and the amount was recorded each time. Growth factors and cytokines production was evaluated as the whole amount produced over a 24‐hour period. In all patients, the amount of drain fluid from surgical wounds was more copious the first day after surgery, it decreased significantly afterward. The presence of all cytokines was highest on postoperative day 1, decreasing over the following days. More specifically, the production of IL‐1 ra, IL‐6, IL‐1α, and IL‐10 on postoperative day 1 fell sharply on postoperative days 3 and 4, whereas, after an initial reduction, interferon‐γ showed an increase from day 2 onward. Vascular endothelial‐derived growth factor production increased progressively after the operation reaching statistical significance only on day 4. As for basic fibroblast growth factor, it showed an opposite pattern: it was higher on postoperative day 1 decreasing thereafter. This analysis of cytokine and growth factor production in the drain fluid will lead us to a better evaluation of the events that follow a surgical wound and to a better understanding of the healing process.

Cytokine modifications after tension-free hernioplasty or open conventional inguinal hernia repair

BACKGROUND The purpose of this study was to evaluate the involvement of proinflammatory cytokines (interferon-gamma [INF-gamma], interleukin [IL]-6) and anti-inflammatory cytokines (IL-4, IL-l0, IL-13) in patients undergoing Lichtenstein tension-free hernioplasty (LH) using polypropylene prosthetic materials or conventional Bassini hernia (BH) repair. METHODS Thirty-five male patients (age range 25 to 60 years) with unilateral inguinal hernia without complications or recurrence were included in this study. Randomly, patients underwent conventional operation and had their inguinal hernia repair performed with polypropylene mesh. Peripheral venous blood samples were collected 24 hours prior to surgery and then 6, 24, 48, and 168 hours postoperatively. Fifteen healthy controls were included. RESULTS We present evidence that LH patients showed both an increased serum level of Thelper 1 (Th1)-like cytokines (IFN-gamma) and an increase in Thelper 2 (Th2)-like cytokines (IL-6 and IL-l0), associated with a slight reduction of peripheral blood mononuclear cells (PBMC) producing IL-6 and a normal level of PBMC producing IFN-gamma, IL-l0, IL-13, and IL-4. Whereas BH patients showed in part an amplification of Th2-like cells, characterized by the sustained serum production of IL-6 and IL-l0, associated with an increase in IL-l0 secreted by in vitro stimulated PMBC. CONCLUSIONS Our data show that LH is associated with a higher production of inflammatory cytokines (IFN-gamma and IL-6) compared with BH, likely induced by the presence of the polypropylene prostheses.

Randomized clinical trial of botulinum toxin injection for pain relief in patients with thrombosed external haemorrhoids

Thrombosed external haemorrhoids are one of the most frequent anorectal emergencies. They are associated with swelling and intense pain. Internal sphincter hypertonicity plays a role in the aetiology of the pain. This study evaluated the efficacy and safety of an intrasphincteric injection of botulinum toxin for pain relief in patients with thrombosed external haemorrhoids.

Intestinal melanoma: A broad spectrum of clinical presentation.

INTRODUCTION Small intestine melanomas are rare and the most of them are metastases from primary cutaneous neoplasms. PRESENTATION OF CASE Below, we report two cases of small intestine metastatic melanoma with very different clinical presentation. DISCUSSION Still now, primary versus metastatic origin is often unclear. Small bowel melanoma is often asymptomatic. However, clinical picture can be various; it may occurs with non specific symptoms and signs of gastro-intetstinal involvement, like chronic abdominal pain, occult or gross bleeding and weight loss, or with an emergency picture due to intestinal intussusception, obstruction or, rarely, perforation. CONCLUSION Small bowel melanoma is rare and the diagnosis done late. Imaging techniques are recommended in order to obtain early diagnosis of gastrointestinal metastases.

Inguinal hernioplasty improves the quality of life in patients with cirrhosis

BACKGROUND The optimal management of symptomatic inguinal hernia (SIH) in cirrhotics is still undefined. Both hernia and cirrhosis impair quality of life (QOL). The aim of this study was to evaluate QOL by a Short Form-36 (SF-36) questionnaire in cirrhotic patients undergoing inguinal hernioplasty. METHODS Thirty-two cirrhotic patients undergoing inguinal hernioplasty were evaluated. They were classified according to Childs class and to the absence or presence of refractory ascites. The SF-36 questionnaire was administered the day before and 6 months after surgery. Global analyses of the 8 domains of SF-36 and of 2 comprehensive indexes of SF-36, Physical Component Summary (PCS) and Mental Component Summary (MCS), were performed. RESULTS Lichtenstein hernioplasty for SIH originated no major complications. All 8 domains of SF-36 and MCS and PCS scores improved remarkably after hernioplasty especially in patients in Childs class C and/or with refractory ascites. CONCLUSIONS Inguinal hernioplasty for SIH in patients with cirrhosis is a safe procedure. The improvement of QOL represents a clear cut indication for elective hernia repair.

Resolution of Ménétrier’s Disease after Helicobacter pylori Eradicating Therapy

Some cases of Ménétrier’s disease associated with Helicobacter pylori (HP) have recently been reported in the literature. We report here the case of a 51-year-old man with a diagnosis of Ménétrier’s disease who had previously been unsuccessfully treated with H2 antagonists. A subsequent demonstration of HP infection led us to treat the patient with an eradicating therapy which prompted complete regression of clinical symptoms, resolution of the gastric endoscopic picture, and absence of HP on gastric histology. This result, in accordance with others in the literature, indicates an eventual association of HP infection with Ménétrier’s disease and that consequent therapy is mandatory.

Impact of different texture of polypropylene mesh on the inflammatory response.

Over the past decade, hernia surgery has undergone a considerable transformation with the use of prosthetic materials. The most used polypropylene meshes induce a rapid acute inflammatory response followed by chronic foreign body reaction. Many factors influence this response such as density, size, physical characteristics, different texture and porosity of each biomaterial. The aim of this study is to assess whether the implant of monofilament or multifilament meshes, in the inguinal hernioplasty, determine a different inflammatory response. Thirty-two male patients were included in the study and were randomly divided into two groups. In the first group (MO) inguinal hernioplasty was performed using monofilament polypropylene mesh, while in the second one (MU) multifilament prosthesis was used. Peripheral venous blood samples were collected 24 hours before surgery and then 6,24,48 and 168 hours posto-peratively. Modifications in leukocyte count, C-reactive protein (CRP), alpha-1 antitrypsin (α1-AT), interleukin (IL)-1, IL-6, IL-1 ra and IL-10 serum levels were recorded at all sampling times. We present evidence that serum levels of CRP, (α1-AT), leukocytes and cytokines were significantly increased post-operatively in both groups, returning to basal values 168 hours afterwards. In particular, the production of all pro-inflammatory mediators was higher in the MU group, whereas the anti-inflammatory cytokine (IL-10, IL-1ra) production was higher in MO patients. Our results indicate that polypropylene multifilament mesh allows a higher intense acute inflammatory response as compared to monofilament mesh implantation.