Savino Occhionorelli

Gasless video-assisted reversal of Hartmann's procedure

More than 60% of patients who are submitted to Hartmanns procedure refuse to undergo reversal. This procedure is in fact a major undertaking associated with significantly mortality and morbidity rates. The authors suggest a minimally invasive approach without pneumoperitoneum.A consecutive series of four male patients, average age 64 years, underwent laparoscopic assisted reversal of Hartmanns procedure in our department. The procedure was performed for intestinal malignant occlusion in two cases and for perforated diverticulitis in the other two. Mobilization was nearly immediate and incisional pain almost absent; peristalsis restarted after 36–48 h. Finally, the patients were discharged on day 6. Neither mortality nor morbidity occurred in the 8-month follow-up period. The authors conclude that this new laparoscopic procedure may lead to shorter hospital stays and increased acceptance by patients, while maintaining the same safety of the traditional open procedure.

CHIVA strategy in chronic venous disease treatment: instructions for users

Along the years, scientific clinical data have been collected concerning the possible saphenous flow restoration without any ablation and according with the CHIVA strategy. Moreover, in 2013 a Cochrane review highlighted the smaller recurrence risk following a CHIVA strategy rather than a saphenous stripping. Nevertheless, the saphenous sparing strategy surely remains a not-so-worldwide-spread and accepted therapeutic option, also because considered not so immediate and easy to perform. Aim of this paper is to provide an easily accessible guide to an everyday use of a saphenous sparing strategy for chronic venous disease, highlighting how even apparently too complicated reflux patterns classifications can be fastly and successfully managed and exploited for a hemodynamic correction.

Necrotizing fasciitis: a surgical emergency.

Accurate assessment and timely interventions are critical in the treatment of patients affected with necrotizing fasciitis, a rare, fulminating, potentially life-threatening, infectious process of the soft tissues. Understanding the natural history and unique characteristics of this disease is crucial to achieve early recognition, effective management and a favorable patient outcome. Classic symptoms include severe pain, erythema, mottling, crepitus, skin anesthesia, warmth, tenderness, bullous formations and edema in the affected area and fever. This article aims at reviewing the information known about this disease, collected from various sources. Radical surgical debridement, broad-spectrum antibiotics, negative pressure wound therapy and hyperbaric oxygen therapy are considered to be the cornerstones of treatment.

Autologous fibroblasts transplant after infliximab administration: a new approach in Crohn's perianal fistulas? Brief clinical report.

The transmural nature of the inflammatory process in Crohn’s Disease (CD) is the most important predisposing factor to the development of anal and perianal fistulae, which occur in 3–80% of patients affected with CD, a variation related to different defining criteria. Although several local and general treatments have been proposed, the management of perianal CD is still considered difficult and unsatisfactory, and the rate of recurrences remains really high. Azathioprine or 6-mercaptopurine, and in many cases, infliximab, have been proposed as alternative therapy to surgery for CD. Infliximab, a monoclonal antibody directed against tumor necrosis factor, has been found effective in the treatment of fistulizing CD. However reopening of apparently healed fistulas (treated only with infliximab infusion, without surgery) is frequent, and it has been related to the persistence of deep fistulas tracts, which could otherwise be detectable using anal endosonography. Novel approaches in healing of chronic wounds include the use of tissueengineered skin substitutes as human autologous fibroblasts; these cells have yet been successfully used for healing of diabetic or venous ulcers. In this preliminary report, the first procedure to manage CD perianal fistulas by combining fistulectomy with a transplantation of autologous fibroblasts seeded onto biocompatible HYAFF scaffolds (three-dimensional biodegradable scaffolds entirely composed of a benzylic ester of hyaluronic acid) is described. The patient was 61 years old, male, who was found affected with CD since 1996 and had undergone several medical approaches (steroid drugs, azathioprine, 6-mercaptopurine administration) with low clinical benefits; in 2001, he underwent surgical bowel resection for ileal multiple stenosis. In January 2004, a relapse of the disease with diarrhoea, perianal pain and fever occurred. Right kidney lithiasis, hepatic angioma and a diffuse thickening of the residual ileum were reported by ultrasonography and computed tomography (CT) exams. The inspection of the perianal region and an anal examination showed a trans-sphinteric fistula with a large abscess in the ischio-rectal fossa. The patient underwent drainage of the abscess and the loose-seton technique was applied; then the patient underwent a series of three infliximab administrations (5 mg/kg/die in a slow drip) at 1, 2, 6 weeks after surgery, followed by azathioprine administration (150 mg/ die) for 2 months. In October 2004, the patient was admitted to the autologous fibroblasts transplantation protocol. The patient was informed about the treatment and agreed to the implant of autologous S. Ascanelli . D. de Tullio . C. Gregorio . G. Azzena . S. Occhionorelli Department of Surgical, Anesthesiological, Radiological Sciences, Surgical Clinic Institute of the University of Ferrara, Ferrara, Italy

Adenocarcinoma Arising in an Elderly Patient’s Large Ileal Duplication

Bowel duplications are rare congenital anomalies commonly found in pediatric patients; few cases may remain undetected until adulthood. Malignant carcinomatous changes are rare complications in intestinal duplications. An 88-year-old female patient was referred to our surgical unit with the diagnosis of a large abdominal mass. An explorative laparotomy was performed, revealing a large (22 × 11 cm) neoplasm strictly connected to the lowest ileal segment and completely filling the pelvis. Definitive histology revealed a moderately differentiated adenocarcinoma developing in a duplication of the terminal ileum. The hypothesis of a gastrointestinal duplication should be evaluated in the differential diagnosis of large, complex, indeterminate masses located in or near the bowel; the possibility of neoplasm within the duplication should be considered.

Acute Abdomen due to Primary Omental Torsion and Infarction

Background. Torsion of greater omentum is a quite uncommon cause of acute abdomen. It can be primary or secondary but in both cases omentum twists upon itself and causes omental segmentary or diffuse necrosis. Symptoms are unspecific and preoperative diagnosis is difficult. The widespread and increasing use of computer tomography (CT) in differential diagnosis of acute abdomen can be useful for making a specific diagnosis. Objectives. This work aims to describe primary omental torsion in order to help avoid misdiagnosis, especially with acute appendicitis, which is eventually based solely on a physical examination. Case Report. We present a case of primary omental torsion in a young man and discuss contemporary methods in diagnosis and management of the condition. Conclusions. When a right diagnosis has been posed, possible treatments for omental torsion and necrosis are two: conservative or surgical. Conservative treatment had been rarely carried out because of frequent and important sequelae just like abdominal abscesses. Nowadays, surgical treatment, laparoscopic or laparotomic, is preferred because it is a safe method in diagnosis and management of this condition.

Peritoneal cystic mesothelioma treated with minimally invasive approach

A case of peritoneal cystic mesothelioma in a young woman was treated with a minimally invasive approach. The technique and a review of the literature are presented.

Benign multicystic mesothelioma of peritoneum complicating acute appendicitis in a man: a case report

BackgroundBenign multicystic mesothelioma is a rare pathology. Few cases are reported in the medical literature and acute presentation is extremely uncommon.Case presentationWe describe an acute clinical presentation of the neoplasm that revealed itself with signs and symptoms attributable to acute appendicitis in a 41-year-old white man. Abdominal echography and computed tomography scans demonstrated the presence of a mass in direct contiguity with cecal fundus, but diagnosis remained unclear. Our patient underwent surgery and complete removal of the neoplasm. Only a definitive histological examination defined the nature of the lesion. No signs of relapse were demonstrated 1 year after the operation.ConclusionsWe showed that an acute presentation of a benign neoplasm represents a diagnostic and therapeutic challenge for the surgeon, because of the difficult differential diagnosis that acute presentation can sometimes pose and the trouble that an emergence treatment can imply.

The calendar of cytokines: Seasonal variation of circulating cytokines in chronic venous insufficiency

Objectives To assess if in chronic venous insufficiency, there is a seasonal variation of cytokines levels which could explain the typical worsening of symptoms during Spring and Summer. Participants From 193 chronic venous insufficiency patients, we selected 32 patients in clinical stage C2–C3 of the Clinical–Etiology–Anatomy–Pathophysiology classification. Design A prospective, comparative and blinded cytokines assessment in two different seasons. Setting We sorted patients by two homogenous groups, 17 Autumn Group and 15 Spring Group. A complete clinical and haemodynamic assessment and laboratory analysis of 22 circulating cytokines were performed on each patient. Main outcome measures Circulating cytokines levels assessment. Results The two groups resulted homogenous for age, gender, clinical class, and haemodynamic parameters. Comparing cytokines expressions in Autumn Group vs. Spring Group, we found a significant difference of 11 out of 22 circulating cytokines (p < 0.05). Particularly Eotaxin, Interleukin-8, Monocyte Chemoattractant Protein-1, Tumour Necrosis Factor-α and Vascular Endothelial Growth Factor were increased in Autumn compared to the Control Group (p < 0.001); while significantly reduced in Spring, within the normal range (p, not significant). Conclusions Symptoms of chronic venous insufficiency are self-reported by patients more intense during warm seasons. Surprisingly, in our study, cytokines levels were significantly higher during Autumn and downregulated in Spring. These variations show for the first time the presence of a ‘Calendar of Cytokines’ in chronic venous insufficiency, which needs to be further investigated.

Femoral vein valve incompetence as a risk factor for junctional recurrence.

Background Recurrent varicose veins occur up to 80% of procedures. The sapheno-femoral junction can be involved in more than 50% of cases. A detailed pathophysiological explanation of the phenomenon is still missing. The aim of the present work is to evaluate the role of femoral vein incompetence as risk factor for sapheno-femoral junction recurrence. Methods Three-hundred-eighty-one patients presenting an incompetent great saphenous vein system and eventually also an incompetent femoral tract (C2-6EpAsdPr) underwent a great saphenous vein high ligation with flush ligation also of the incompetent tributaries along the leg, sparing the saphenous trunk. Pre-operatively, all patients underwent a sonographic evaluation assessing the superficial and deep venous systems, including a detailed analysis of the iliac-femoral vein tract above the sapheno-femoral junction. A retrospective statistical analysis assessed the recurrence risk associated with iliac-femoral vein tract incompetence. Results In a 5.5 ± 1.9 years follow-up, great saphenous vein trunk reflux recurrence was detected in 45/381 (11.8%) cases. The reflux source was found in a reconnected sapheno-femoral stump in 11/45 cases (24.5%), in the pelvic network in 8/45 cases (17.8%), in a neovascularization process in 7/45 (15.5%) and in a newly incompetent great saphenous vein tributary in 19/45 (42.2%). At the pre-operative assessment, iliac-femoral vein tract reflux was present in 7 (26.9%) of the 26 cases who developed a sapheno-femoral junction recurrence and in 25 (7%) of the 355 patients who did not demonstrate sapheno-femoral junction recurrence (odds ratio: 4.8; confidence interval 95%: 1.8–12.6; p < .003). Discussion Despite many technical diagnostic and therapeutic refinements, varicose veins recurrence remains a frequent event. The present investigation points out the association among iliac-femoral vein tract incompetence and sapheno-femoral junction recurrences after high ligation.