Emergency surgical treatment of complicated acute diverticulitis

Twenty-five percent of patients undergoing surgery for acute complicated diverticulitis represent emergencies. This condition is currently treated by colonic resection with primary anastomosis with or without colostomy, or by a Hartmann operation. We report on our experience with 52 consecutive patients with generalized peritonitis (8 cases), peri- and paracolonic abscesses (19 cases), severe pelvic abscesses (12 cases) and multiple abscesses with visceral fistulas (13 cases). All patients had emergency surgery. In 50/52 patients (96.2%) we performed a colonic resection with primary anastomosis using a mechanical stapler and in 2/52 a Hartmann operation. The overall mortality rate was 5.8%. The morbidity rate was 22% with 9 anastomotic leakages. A diverting colostomy was constructed in 16 patients and opened in only 8 patients. In 4 cases a parastomal hernia occurred after late closure and reduction of the colostomy. This data suggest that colonic resection with primary anastomosis, even without colostomy, is a safe procedure for the emergency treatment of acute complicated diverticulitis.     

The usefulness of antibiotic prophylaxis in invasive urodynamics in postmenopausal female subjects

This study aims to define the usefulness of antibiotic prophylaxis of urinary tract infection (UTI) in postmenopausal female undergoing invasive urodynamics (IU). Two hundred sixty-two postmenopausal females underwent IU. Before urodynamics, all females were double blindly randomized in two age stratified groups. Group 1 (130 patients) received oral antibiotic prophylaxis with a single 400-mg dose of norfloxacin. Group 2 (132 patients) received norfloxacin placebo. Statistical analysis was performed by a chi (2) test to evaluate differences between groups for UTI incidence rate. Fifty-four patients of 262 (20.6%) resulted affected by UTI [24 of 130 subjects who received antibiotic prophylaxis (18.4%) and 30 of 132 subjects who received placebo (22.7%)]. There was no statically significant difference (P = 0.242) regarding UTI incidence rate between patients who received and those who did not received antibiotic prophylaxis. UTI incidence rate in postmenopausal women undergoing urodynamics is not affected by administration of antibiotic prophylaxis at the desired level of efficacy.     

Surgical Treatment of Peyronie's Disease by Plaque Incision and Grafting with Buccal Mucosa

Background

Plaque incision and tunical grafting is widely used to correct penile curvatures secondary to Peyronie's disease (PD), but there is no consensus on the ideal graft to be used.

Objective

To evaluate the efficacy, safety, and reproducibility of plaque incision and buccal mucosa grafting (BMG) in the correction of severe penile curvatures secondary to PD.

Design, setting, and participants

Fifteen patients reporting normal erections and stable curvature (>12-mo duration) entered this prospective study carried out at two university hospitals.

Intervention

All patients underwent plaque incision and BMG.

Measurements

Preoperative evaluation included the International Index of Erectile Function (IIEF-5) and penile duplex ultrasounds with measurement of curvature and length of affected side. Follow-up visits were scheduled at 1, 3, 6, and 12 mo postoperatively, then yearly. Three-mo postoperative evaluation included IIEF-5, patient and partner satisfaction, and intracavernous injection test with evaluation of penile rigidity, straightness, and length; patient and partner satisfaction was recorded at all subsequent visits.

Results and limitations

Mean patient age was 56.3 yr and mean penile curvature 72°; five patients had a two-sided curvature with mean second curvature of 37°. There were no complications. All patients resumed unassisted intercourse 1 mo after surgery. Three-mo postoperative evaluation showed 100% penile straightening, 1.8-cm mean increase in length of affected side, no curvature recurrence or de novo erectile dysfunction, 1.6 mean increase in IIEF-5 score, and patient and partner satisfaction of 93.3% and 100%, respectively. Although results remained stable at subsequent follow-up (mean 13.1 mo), a greater number of patients and longer follow-up are needed before drawing any definite conclusions.

Conclusions

BMG provided excellent short-term results, probably because its prompt revascularisation, suggested by the fast return of spontaneous erections, prevented shrinkage, which is the main cause of graft failure. It also proved to be safe and reproducible, thus representing a valuable treatment option for PD.     

Bilateral total hip arthroplasty in subjects with multiple epiphyseal dysplasia

Multiple epiphyseal dysplasia (MED) is a rare autosomal dominant skeletal dysplasia caused by abnormalities in the gene(s) coding for type IX collagen and cartilage oligomeric matrix protein. Clinically, the disease is characterized by abnormalities in the epiphyseal cartilage of multiple joints. Orthopedic manifestations include pain and restricted mobility. The disorder, which has a predilection for the femoral head and acetabulum, usually presents from the third to the fourth decade with secondary hip osteoarthritis. We report on 7 subjects affected by multiple epiphyseal dysplasia, which presented hip osteoarthritis in their third decade of life and underwent staged bilateral total hip arthroplasty. All patients experienced pain relief and improved quality of life after surgical treatment.     

Full robot-assisted gastrectomy: surgical technique and preliminary experience from a single center

The treatment of gastric cancer requires a multidisciplinary approach in which surgery plays the main role. The diffusion of minimally invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended lymphadenectomy. This surgical step can be facilitated through the use of a robot-assisted system. To date, there are few published articles discussing a full robotic approach that precisely show the different surgical steps. The aim of this study is to describe our experience, surgical techniques and the short-term results of a consecutive series of full robotic gastrectomies using the Da Vinci Surgical System. From November 2011 to January 2015, 17 patients with gastric cancer underwent curative resection by robotic approach for locally advanced tumors. In summary, there were 15 total gastrectomies with a Roux-en-Y esophagojejunostomy, one total gastrectomy with transverse colectomy and one sub-total gastrectomy. Resection margins were negative in all cases. Conversions occurred in two patients. Robot-assisted gastrectomy with extended lymphadenectomy is a safe technique and successfully allows an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity. The learning curve appears to be shorter than in laparoscopic surgery. Further follow-up and randomized clinical trials are required to confirm the role of a robotic approach in gastric cancer surgery.     

Pitfalls of midface surgery

The endoscopic forehead midface lift is perhaps the most powerful tool has been made available to the facial aesthetic surgeon in the last 10 years. Although this technique can reap the greatest rewards, it is also fraught with the greatest peril. A difficult dissection, prolonged period of edema, and numerous other pitfalls have tempered enthusiasm among facial aesthetic surgeons for this powerful technique. Nonetheless, the midface lift can be performed both safely and effectively. Through careful analysis of the pitfalls of midface surgery, one can adopt principles that help prevent or minimize potential complications. Such an approach can maximize the surgical benefit to the patient and lessen the anxiety surrounding the procedure for the patient and surgeon alike.     

Iatrogenic splenic injuries

Inadvertent intraoperative injuries to the spleen by the surgical team represent an underestimated complication of many abdominal procedures. Surgical reports often lack the necessary details and frequently a clear justification as why a splenectomy was indicated is not provided. The wide variability of the incidence reported in literature makes it is difficult to evaluate the morbidity and mortality associated to these injuries and to assess the early and late consequences of this complication, although it is still possible to infer some of the reasons for these inconsistencies and to roughly estimate both clinical and socio-economical effects of this injury. Given the degree of uncertainty on the incidence of iatrogenic and traumatic splenic injuries and on the immediate and long-term sequelae suffered by asplenic patients, we thought that a multicentric prospective study was warranted. We are therefore announcing the start of a study involving several Institutions within the Regione Campania, aimed at obtaining an unbiased estimate of the incidence of these injuries, together with the extent and severity of their long-term complications. We also aim to help promoting a more effective prevention.     

Circulating levels of adhesion molecules in chronic kidney disease correlate with the stage of renal disease and with C-reactive protein

BACKGROUND: Patients with chronic renal failure (CRF) suffer from a series of complications linked to the atherosclerotic process in which the endothelial dysfunction mediated by the activation of some adhesion molecules plays an important role. This study aims to evaluate circulating levels of intercellular adhesion molecules-1 (ICAM-1) and vascular cell adhesion molecules-1 (VCAM-1) in patients with predialysis CRF, on maintenance hemodialysis (HD) and after kidney transplantation (KTx) and to correlate them with some inflammation and nutritional indexes. METHODS: Thirty two patients with predialysis CRF, 30 on maintenance HD, 36 after KTx and 28 subjects as a control group (C) were included in this study. Circulating levels of ICAM-1 and VCAM-1 were assayed using a specific sandwich ELISA kit. As inflammation indexes, TNFalpha and C-reactive protein (CRP) and, as nutritional indexes, body mass index (BMI), serum albumin, cholesterol, triglycerides, and fibrinogen (F) were evaluated. RESULTS: Serum levels of ICAM-1 and VCAM-1 were progressively higher from C to KTx patients, to those with CRF and those on HD (ANOVA for both; p <0.001). TNFalpha values were lower in HD subjects than in CRF patients, even if in both groups TNFalpha levels were greater than in Tx and control subjects. F and CRP were higher in CRF and HD vs. Tx and control subjects (ANOVA for both p <0.001). No significant correlations were observed between soluble adhesion molecules, albumin and cholesterol, whereas significant correlations were found between CRP and ICAM-1 (r = 0.41; p <0.01), CRP and VCAM-1 (r = 0.39; p <0.01) and between CRP and TNFalpha (r = 0.42; p <0.01). These correlations remained statistically significant even after adjustment for age and blood pressure (all p <0.01). BMI did not differ in the three patient groups. CONCLUSIONS: Circulating levels of adhesion molecules in our study correlated positively with the stage of disease and with one of the inflammatory indexes (CRP), but not with nutritional indexes such as BMI, cholesterol and albumin. The clinical significance of our findings warrants further investigation.     

Liver frailty and all-cause mortality in the older participants of the Salus in Apulia Study

The liver contribution to the biological network underlying physical frailty in aging is underestimated. How best to measure this contribution magnitude and impact on health risk trajectories in frail individuals is not yet entirely clear. We analyzed the association of a novel liver frailty phenotype with the risk of death in older participants of the Salus in Apulia Study cohort. Clinical and physical examination, routine biomarkers, medical history, and anthropometry were analyzed in 1929 older adults (65?+). Physical frailty was classified by Cardiovascular Health Study criteria, and liver fibrosis risk by fibrosis-4 (FIB-4). The liver frailty phenotype was defined as physical frailty plus high-risk liver fibrosis (score?>?2.67). Physical frailty, high-risk liver fibrosis, and liver frailty subjects were compared to subjects without these conditions (non-frail). Proportional Cox regression tested the adjusted association between liver frailty and all-cause mortality for each category. The liver frailty prevalence was relatively low (3.8%), but higher in men (58.1%). Compared to non-frail older subjects, liver frailty subjects were significantly older (effect size (ES)???1.11, 95% confidence interval (CI)???1.35 to???0.87), with a lower education (ES 0.48, 95%CI 0.24 to 0.71) and higher multimorbidity (ES 15.81, 95%CI 4.20 to 27.41). Cox multivariate analyses showed a two-fold increased risk of overall mortality (hazard ratio 2.09, 95%CI 1.16–3.74) even after the adjustment for age, sex, education, and alcohol consumption. The liver frailty phenotype runs twice the risk of overall mortality compared with the non-frail population. This clinical tool, validated in a Southern Italian population, is based on simple sets of measures that can conveniently be assessed also in the primary care setting.

     

Mesenteric Cyst with GI Symptoms: A Fluid Approach to Treatment—Case Report and Literature Review

Digestive Diseases and Sciences - Mesenteric cysts are defined as a heterogeneous group of intra-abdominal cystic lesions of the mesentery or omentum that may be found in any portion of the...