Rectal bleeding by Dieulafoy-like lesion: successful endoscopic treatment

A 81-year old woman affected by chronic renal failure, non insulin-dependent diabetes mellitus (NIDM) and hypertension, had an severe anemia massive hematochezia. The colonoscopy could not localize the bleeding site except some blood spots in the rectum. The patient was readmitted after 1 month with hypovolemic shock by massive hematochezia and required several blood transfusions. The endoscopic examination showed an important arterial bleeding treated successfully with epinephrine and bipolar elettro-coagulation (BICAP). We suggested that the patient presented a Dieulafoy-like lesion; this is an uncommon gastrointestinal cause of bleeding due to a defect of a submucosal artery without evidence of atherosclerosis or vasculitis. Both chronic renal failure and age could be considered as predisponent factors in this patient. Hematochezia is the most important sign and is often complicated by haemorrhagic shock. The diagnosis was delayed due to the difficulty in localizing the bleeding site; moreover, the patient needed several blood transfusions. The arteriographic diagnosis associated to endoscopic treatment by epinephrine and BICAP enabled a successful therapy.     

Hospitalization After Open Colectomy: Expectations and Practice in General Surgery

Purpose There is increasing pressure to reduce the length of stay (LOS) in hospital after colectomy. To assess the impact of unintended variations on LOS, actual discharge management was compared with the expectations expressed by general surgeons.Methods We retrospectively examined 262 patients who underwent elective open colectomy. The effects of patient demographics, surgical variables, and functional recovery on postoperative LOS were assessed in univariate and multivariate models. We also used a structured questionnaire to assess the expectations of surgeons regarding criteria affecting patient discharge.Results The median LOS was 11 days, which was univariately correlated with morbidity, bowel movement, oral feeding, mobilization, surgeon, rectal procedures, comorbidity, type of analgesia, blood transfusion, and colorectal cancer. According to the multivariate analysis, morbidity (P < 0.001), colorectal cancer (P = 0.026), rectal procedure (P = 0.037), and analgesia (P = 0.04) were correlated with LOS. The surgeons we interviewed believed that discharge should be based on the return of bowel movement and the absence of morbidity. By discharging our patients on postoperative day 5 or 6, these criteria would have been respected in 84% and 88%, respectively.Conclusion Prolonged hospitalization after colectomy persists when critical pathways are not observed and there is a lack of institutional pressure to reduce to the LOS. Many factors affect the delay in patient discharge, possibly reflecting unwanted variation rather than the surgeons expectations.     

Pitfall in renal cyst surgery: serous cystadenoma of pancreas mimicking renal cyst

Pancreatic lesions, particularly cysts, can simulate various diseases. We report a case of a 43-year-old woman with a large, symptomatic, retroperitoneal cyst misdiagnosed as a "renal cyst." During the retroperitoneoscopic marsupialization, the correct diagnosis of a pancreatic cyst was made, leading to an open pancreas tail resection. Histologic evaluation revealed serous cystadenoma. Especially in large retroperitoneal cysts on the left side, the correct diagnosis of a pancreatic cyst can be difficult.     

Tardive cecal metastasis from ovarian cancer: a case report

Intestinal insolvement is a frequent sequela of metastatic ovarian cancer may be syncronous or following ovaric resection, after several years of disease free condition. The authors herein describe a clinical report of a case of cecal metastatic neoplasm due to ovarian cancer treated with surgical resection 24 years before.     

Acute appendicitis associated to "serrated" adenoma: a case report

The authors describe a case of acute appendicitis associated "serrated" adenoma (SA). to the histological finding of a SA is a colorectal pre-cancerous lesion which presents the morphological and architectural characteristics of hyperplasic polyps, combined with aspects of adenomatous dysplasia. SA can eventually evolve into a malignant cancer, similarly to classic adenomatous polyps. Clinical and pathological aspects of this lesion are hereby analysed, with respect to recent Literature data.     

The physicochemical characteristics and bioavailability of indomethacin from beta-cyclodextrin, hydroxyethyl-beta-cyclodextrin, and hydroxypropyl-beta-cyclodextrin complexes

In an effort to improve the bioavailability of the insoluble drug indomethacin, three complexes were prepared with indomethacin and the soluble complexing agents β-, hydroxyethyl-β-, and hydroxypropyl-β-cyclodextrin. The indomethacin content was similar among the complexes (P≤0.05). To confirm complex formation, each complex was characterized by ultraviolet, infrared, nuclear-magnetic resonance, powder X-ray diffraction, and differential-scanning calorimetry techniques. Powder diffraction studies show the β-cyclodextrin complex was polycrystalline, and the hydroxyethyl- and hydroxypropyl-β-cyclodextrin complexes were amorphous. Phase-solubility analysis confirmed the formation of complexes and suggested the three complexes were bound similarly. Solubility studies show complexation increased indomethacin solubility, and the hydroxyethyl- and hydroxypropyl-β-cyclodextrin complexes were more soluble than the β-cyclodextrin complex in 0.1N hydrochloric acid and distilled water. Dosage forms were prepared by encapsulating the complexes without the addition of excipients. Dissolution studies show the encapsulated β- and hydroxyethyl-β-cyclodextrin complexes had superior dissolution when compared to the hydroxypropyl-β-cyclodextrin and Indocin^® (50 mg) capsules. Bioavailability studies were performed by administering the indomethacin complex or Indocin capsules to male-albino, New Zealand rabbits. Indomethacin plasma-time concentration data fit best to a compartment-independent model for all capsule formulations. Bioavailability comparisons by ANOVA show no significant difference (P≤0.10) in the peak-plasma time and peak concentration among the capsule formulations. The area-under-the-curve for the β-cyclodextrin complex capsules was found to be significantly higher (P≤0.10) than all other capsule formulations. In conclusion, the bioavailabilty of indomethacin was improved by complexation with only β-cyclodextrin. No correlations were found among the bioavailability, solubility, and dissolution results.     

The principles of tissue engineering: role of growth factors in the bone regeneration

In this article the principles of tissue engineering are analyzed. The growth factors release from platelets, TGF-beta, PDGF, IGF-I and -II, are accurately described and the structure and functions of these growth factors are reported. Then a simple model of bone regeneration is proposed. This model is used every time that bone grafts are used in oral and maxillofacial surgery. On the basis of this model of bone regeneration, the cells and biochemical indicators (pH and pO2) of bone wound where the bone graft is placed, and of surrounding tissues, are described. Then three phases of bone regeneration are analyzed: the beginning, the second (or immature bone), the third or mature bone with lamellar architecture. In each phase the importance of growth factors are evaluated. The conclusion is drawn that factors influence the bone regeneration and that their increased concentration leads to a quick bone formation and quantity. Moreover, the techniques of regeneration in vivo with autogenous bone, are better than those in vitro, since the bone structure, is also the result of the biomechanical environment, where the bone graft grows up.     

Hypocalcemic tetany due to coeliac disease. May this symptoms disappear?

We described a rare case of hypocalcemia whit tetanic symptoms. This condition of our patient could be avoided if some symptoms, present from many years, were diagnosed as factors related to coeliac disease, anemia was present from many years and it was more important during four pregnancies. The appearance of diffuse bone pain from two years is correlated to a metabolic osteopathy due to coeliac disease. Unexplained increase of liver enzymes is an expression of coeliac disease. We stress the importance to always consider extra-intestinal manifestation of coeliac disease in every patients, because this disease has an high incidence (1 in 200 people). Our patient could had important clinical advantages, if his disease was diagnosed by extra-intestinal alterations (anaemia, bone pain and increased blood levels of liver enzymes in our patient). Coeliac disease must be researched in every different and particular clinical and sub-clinical manifestation; in 65% of all cases, the patients with coeliac disease haven't gastrointestinal symptoms.     

Long-term remission of type 2 diabetes in morbidly obese patients after sleeve gastrectomy

BackgroundThe aim of this study was to evaluate the long-term effects of laparoscopic sleeve gastrectomy (LSG) on type 2 diabetes mellitus (T2DM) and other related co-morbidities in severely obese patients.MethodsFrom May 2003 to July 2008, 33 morbidly obese diabetic patients (20 with body mass index [BMI]>50 kg/m²) underwent LSG. A total of 23 females and 10 males participated, with a mean age of 49.3±8 years, mean preoperative BMI of 52.1±8.5 kg/m², mean fasting plasma glucose (FPG) of 143.2±47.9 mg/dL, mean glycosylated hemoglobin (HbA_1c) of 7.3%±1.4%, and a mean T2DM duration of 7 years. All patients had a 36-month follow-up, and 13 had a 60-month follow-up.ResultsTwenty-nine patients (87.8%) discontinued antidiabetic medications 3 months after LSG, (mean BMI of 42.8±7.8 kg/m²; FPG of 104.5±22.1 mg/dL; HbA_1c of 5.3%±.4%). At 36 months, 22 of 26 LSG patients (84.6%) had normal FPG and HbA_1c values without antidiabetic therapy. At the 60-month follow-up, 10 of 13 patients (76.9%) had normal FPG and HbA_1c values without antidiabetic therapy. The Framingham risk score decreased significantly from 9.7% preoperatively to 4.7% postoperatively. No new diabetic retinopathy occurred during the whole period of observation.ConclusionsThis study confirms the efficacy of LSG in the treatment of T2DM and indicates that, at both 36- and 60-month follow-ups, LSG can provide a significant percentage of treated patients with a prolonged remission of T2DM, with diminished cardiac risk factors and no development of diabetic retinopathy. These results compare favorably with those reported after standard medical therapy.