Sergio Leardi

Synovial sarcomas are rare malignant tumors of soft tissues, arising mainly from periarticular structures. Gastrointestinal localizations are unusual presentation of these rare sarcomas. We present the case of a 56- years old man with monophasic synovial sarcoma, arising primarily from the ileum, and causing intussusception. A review of the literature was conducted to gather information about this rare sarcoma. We found that the criteria normally used to determine the prognosis in patients with monophasic synovial sarcoma of soft tissue are poorly applicable for gastrointestinal localizations. A better characterization of these tumors could identify them as a distinct entity, compared with monophasic synovial sarcomas of soft tissues.

Fournier's gangrene is a rapidly progressing necrotizing fasciitis, involving perineal, perianal, or genital regions, and it constitutes a true surgical emergency. Surgical excision of all necrotic tissue is required, and multiple debridements may be necessary to remove all nonviable tissue. After surgical intervention for debridement, reconstruction may be necessary. We present our experience in the treatment of tissue loss after Fournier's gangrene of genital and perianal regions with the use of biological mesh (derma porcine mesh) in association with vacuum-assisted closure therapy.

Stapled Transanal Rectal Resection (STARR) has been proposed for surgical treatment of rectal intussusception and rectocele. This study aims at evaluating the effect of the STARR on symptoms of obstructed defecation and associated faecal incontinence regarding the impact on the quality of life of patients with rectal intussusception and rectocele. Twenty-nine patients with rectal intussusception and 22 with rectocele, who underwent to STARR in the General Surgery of the University of L'Aquila-Italy, are the subjects of the study. Symptoms of obstructive defecation were reported in all cases; with associated faecal incontinence in 31%. Questionnaires as ODS-Score, PAC-QoL, FISI and FIQL were proposed to all 51 patients before surgical treatment and at 3 years from operation. ODS-Score decreased from 28 ± 3.66 preoperatively to 6.7 ± 5.77 postoperatively ( p< 0.001), while PACQoL score was 14 ± 1.4 preoperatively vs 5.3 ± 1.7 postoperatively ( p<0.0020). The lower score indicates a lower severity index and an excellent quality of life. FISI score arose from 16.13 ± 5.39 before surgery to 19.33 ± 2.31 after surgery while, in the group of patients with preoperative symptoms of faecal incontinence, it arose from 7.86 ± 2.89 to 16.4 ± 4.5 after surgery (p< 0.0039). FIQL score sum was 105 ± 75 preoperatively vs 225 ± 90 postoperatively. The lower score indicates a higher severity index and a lower quality of life. Patients with rectal intussusception or rectocele may improve their symptoms and quality of life undergoing to the STARR.

There are few published reports on the outcomes of ≥ 10 years after a laparoscopic floppy Nissen fundoplication (LFNF). From April 1994 to January 2012, 567 patients underwent LFNF and the outcomes of 211 cases were determined (from April 1994 to October 2000). Outcomes at ≥ 11 years after surgery was available for 178 patients (84.3%) of which 167 (93.8%) had no heartburn or mild heartburn, 8 (4.5%) had moderate heartburn, and 3 had (1.7%) severe heartburn. Dysphagia was nonexistent or mild in 153 (85.9%), whereas the remaining 14.1% presented moderate to severe symptoms. Reports of 69.1% patients showed none or mild symptoms of abdominal bloating, that of 23% patients showed moderate discomfort, and reports of 7.8% showed severe bloating. Satisfaction score was 8.6 (of 10). A further surgical procedure was required for 7 patients (3.9%): 4 for recurrent reflux and 3 for dysphagia (2 for a tight wrap and 1 for a tight esophageal hiatus). Postoperative dysphagia sufficient for an endoscopic dilatation was observed in 4 patients (2.3%), where 3 were successfully managed with a single dilatation procedure and the last patient underwent several dilatations before adequate swallowing. LFNF is an effective long-term treatment for gastroesophageal reflux disease, yielding similar results to open fundoplication.

Aim: This study want to examine (a) whether neutrophils, the neutrophil-elastase, C-reactive protein and the Interleukin6 are modified and how, in patients after laparoscopic cholecystectomy open cholecystectomy; (b) whether these findings are indicative of an increased risk to develop infectious complications. MATERIALS OF STUDY: Circulating Interleukin-6 level, C-reactive protein and neutrophil-elastase were measured in 71 patients (35 underwent open cholecystectomy and 36 laparoscopic cholecystectomy). The diagnosis was confirmed by ultrasound examination. During hospitalization the patients were not given antispastic drugs, steroids, or nonsteroidal antiinflammatory drugs (NSAID). RESULTS: The increase in the serum Interleukin-6 and neurtophil-elastase, during laparoscopic cholecystectomy, was found to be significantly smaller than that during open cholecystectomy and resulted in a smaller extent of postoperative elevations for C-reactive protein. We recorded three cases (8.5%) of postoperative infections in the "open" group and neutrophil-elastase values normalized later in patient with complications. CONCLUSION: There were significant associations between the response areas of Interleukin-6 C-reactive protein and neutrophil-elastase levels. Neutrophils-elastase level is a more sensible inflammatory marker in comparison to the IL-6 and C-reactive protein. Excessive and prolonged post injury elevations of these mediators are associated with increased morbidity.

Systemic inflammation and immune response after laparotomy vs laparoscopy in patients with acute cholecystitis, complicated by peritonitis

We focus on the diagnostic and therapeutic problems of duodenal adenocarcinoma, reporting a case and reviewing the literature. A 65-year old man with adenocarcinoma in the third duodenal portion was successfully treated with a segmental resection of the third part of the duodenum, avoiding a duodeno-cephalo-pancreatectomy. This tumor is very rare and frequently affects the III and IV duodenal portion. A precocious diagnosis and the exact localization of this neoplasia are crucial factors in order to decide the surgical strategy. Given a non-specificity of symptoms, endoscopy with biopsy is the diagnostic gold standard. Duodeno-cephalo-pancreatectomy (DCP) and segmental resection of the duodenum (SRD) are the two surgical options, with overlapping morbidity (27% vs 18%) and post operative mortality (3% vs 1%). The average incidence of postoperative long-term survival is 100%, 73.3% and 31.6% of cases after 1, 3 and 5 years from surgery, respectively. Long-term survival is made worse by two factors: the presence of metastatic lymph nodes and tumor localization in the proximal duodenum. The two surgical options are radical: DCP should be used only for proximal localizations while SRD should be chosen for distal localizations.

Intramural hematoma of the colon is rare. It may be "spontaneous" in patients with anticoagulant therapy or blood dyscrasia or caused by blunt abdominal trauma. An uncertain origin is also reported, so we have also "idiopathic hematoma". The AA report a new case of uncertain origin and review the literature. The diagnosis is difficult. Symptoms and signs of intestinal obstruction or colic bleeding are often present. Rx plain abdomen and colonoscopy are not diriment. Angio-TC is useful for detailed diagnosis. Resection of colic segment with hematoma is the gold standard therapy, but evacuation of hematoma might be considered. The reported data show that also colic intramural hematoma should be taken into account in cases of colic obstruction or bleeding. This diagnosis should be considered specially in patients with anticoagulant therapy or referred blunt abdominal trauma.

Stapled hemorrhoidopexy is a widely used surgical technique for treating hemorrhoids, although severe complications have been reported. The authors report a rare case of extensive ascending intramural hematoma of the sigmoid colon complicating stapled hemorrhoidopexy, with perforation and hemoperitoneum. Diagnosis was established at CT scan and treatment consisted of drainage, suturing, and diverting colostomy. This reported case is the ninth described in the literature, but, so far, it is not known what preventive measures to use in order to avoid such a rare complication. Adoption of a correct surgical technique remains the step of utmost importance in order to prevent such a severe postoperative complication.