Endoscopic Resection of a Large Colonic Lipoma: Case Report and Review of Literature

Colonic lipomas are uncommon, benign, submucosal adipose tumors that are usually asymptomatic. Large lipomas can cause symptoms such as constipation, abdominal pain, rectal bleeding and intussusception. We report the case of a 60-year-old man with a history of lower abdominal pain and pseudoobstructive symptoms. Colonoscopy revealed a large polypoid sessile lesion in the sigma. We used a standardized technique of polypectomy, preceded by submucosal injection of dilute 5 ml polygelin with epinephrine 1:10,000 solution, to fully resect large colonic lipomas. The lipoma size was 3.5 cm. No bleeding or perforation developed. Histology showed the polyp to be a submucosul lipoma. On follow-up, there was no residual lesion. Colonic lipomas larger than 2 cm can be safely and efficaciously removed using electrosurgical snare polypectomy technique. The technique of submucosal injection before resection and using an electrocautery snare appears to be safe and reduces the risk of perforation reported in the literature

Hospitalisation among immigrants in Italy

BACKGROUND: Immigration is increasing in Italy. In 2003, 2.6 million foreign citizens lived in the country; 52% were men and the majority were young adults who migrated for work. The purpose of this study was to investigate differences in hospitalisation between immigrants and the resident population during the year 2000 in the Lazio region. METHODS: Hospital admissions of immigrants from Less Developed Countries were compared to those of residents. We measured differences in hospitalisation rates and proportions admitted. RESULTS: Adult immigrants have lower hospitalisation rates than residents (134.6 vs. 160.5 per thousand population for acute care; 26.4 vs. 38.3 for day care). However, hospitalisation rates for some specific causes (injuries, particularly for men, infectious diseases, deliveries and induced abortions, ill-defined conditions) were higher for immigrants than for residents. Immigrants under 18 years seem to be generally healthy; causes of admission in this group are similar to those of residents of the same age (respiratory diseases, injuries and poisoning). The only important differences are for infectious and parasitic diseases, with a higher proportion among immigrant youths. CONCLUSION: The low hospitalisation rates for foreigners may suggest that they are a population with good health status. However, critical areas, related to poor living and working conditions and to social vulnerability, have been identified. Under-utilisation of services and low day care rates may be partially due to administrative, linguistic, and cultural barriers. As the presence of foreigners becomes an established phenomenon, it is important to evaluate their epidemiological profile, develop instruments to monitor and fulfil their specific health needs and plan health services for a multi-ethnic population

Surgical Treatment of Coledochal Cyst Associated with an Aberrant Posterior Hepatic Duct: Report of a Case and Brief Literature Review

Choledochal cysts (CCs) are rare congenital cystic or fusiform dilatations of the biliary tree that can involve the extrahepatic and/or intrahepatic biliary tree. We report a case of huge type I CC associated with an aberrant posterior hepatic duct. A 52-year-old man presented with a 3-week history of upper right abdominal pain and jaundice and serologic sign of obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography were performed with the diagnosis of CC type I according to the classification of Alonso-Lej and Todani-Watanabe. The indication for surgical resection was posed. The cyst was completely resected and the biliary tract was reconstructed with a double hepatico-jejunostomy using the same Roux limb, since during the surgical dissection a before unrecognized anatomical variation of the right biliary tree (aberrant posterior hepatic duct at VI–VII segment) was identified. The diagnosis of CC is often difficult and US and magnetic resonance cholangiopancreatography are necessary to definite biliary dilatation. Endoscopic retrograde cholangiopancreatography should be the most definitive and reliable procedure for the diagnosis and treatment of bilio-pancreatic disorders. Gold standard treatment is surgery (bilio-jejunostomy) and frozen-section histology should be performed to rule out the presence of cancer. In conclusion, surgery is the gold standard for the treatment of CC type I and does not depend on the age of patients, based on a substantial lifetime risk of developing cholangiocarcinoma. Preoperative study is mandatory to assess the biliary tree morphology and to research any anatomical variation

Is Nasobiliary Tube Really Safe? A Case Report

A case of esophageal ulcer caused by nasobiliary tube is described. This tool is not routinely considered to be a cause of major complications in the literature and to our knowledge, this is the first report of this kind of complication in nasobiliary tube placement. A 72-year-old patient presented with Charcot's triad and was demonstrated to have cholangitis with multiple biliary stones in the common bile duct. Biliary drainage was achieved through endoscopic retrograde cholangiography, endoscopic sphincterotomy, biliary tree drainage and nasobiliary tube with double pigtail. The patient presented odynophagia, dysphagia and retrosternal pain 12 h after the procedure and upper endoscopy revealed a long esophageal ulcer, which was treated conservatively. This report provides corroboration of evidence that nasobiliary tube placement has potential complications related to pressure sores. In our opinion this is a possibility to consider in informed consent forms

Predictors of nonfetal reinfarction in survivors of myocardial infarction after thrombolysis Results of the gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) data base

AbstractObjectives. This study was designed to reassess the prediction of recurrent nonfatal myocardial infarction in patients recovering from acute myocardial infarction after thrombolysis.Background. Recurrent nonfatal myocardial infarction is a strong and independent predictor of subsequent mortality. Current knowledge of risk factors for nonfatal reinfarction is still largely based on data gathered before the advent of thrombolysis. Thus, this prospective study was planned to identify harbingers of nonfatal reinfarction in the postinfarction patients of the multicenter Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial.Methods. Predictors of nonfatal reinfarction at 6 months were analyzed by multivariate technique (Cox model) in 8,907 GISSI-2 survivors of myocardial infarction with clinical follow-up, relying on a set of prespecified variables reflecting residual ischemia, left ventricular failure or dysfunction, complex ventricular arrhythmias, comorbidity as well as demographic and historical factors.Results. The postdischarge to 6-month incidence rate of nonfetal reinfarction was 2.5%. Independent predictors of nonfatal reinfarction were cardiac ineligibility for exercise test (relative risk 2.97, 95% confidence interval [CI] 1.98 to 4.45), previous myocardial infarction (relative risk 1.70, 95% CI 1.22 to 2.36) and angina at follow-up (relative risk 1.50, 95% CI 1.10 to 2.04). On further multivariate analysis, performed in 6,580 patients with both echocardiographic and electrocardiographic monitoring data available, a history of angina emerged as an additional risk predictor (relative risk 1.58, 95% CI 1.10 to 2.25).Conclusions. The 6-month incidence of nonfatal reinfarction is rather low in survivors of myocardial infarction after thrombolysis. Cardiac ineligibility for exercise testing and a history of coronary artery disease are risk predictors. Recurrent nonfatal infarction is not predictable by qualitative variables reflecting residual ischemia, except by postdischarge angina. Prediction of nonfatal reinfarction appears less accurate than prediction of mortality, as almost 50% of reinfarctions occur in patients without any of the identified risk factors

Epidemiology and Microbiology of Skin and Soft Tissue Infections: Preliminary Results of a National Registry

Skin and soft tissue infections (SSTIs) represent a wide range of clinical conditions characterized by a considerable variety of clinical presentations and severity. Their aetiology can also vary, with numerous possible causative pathogens. While other authors previously published analyses on several types of SSTI and on restricted types of patients, we conducted a large nationwide surveillance programme on behalf of the Italian Society of Infectious and Tropical Diseases to assess the clinical and microbiological characteristics of the whole SSTI spectrum, from mild to severe life-threatening infections, in both inpatients and outpatients. Twenty-five Infectious Diseases (ID) Centres throughout Italy collected prospectively data concerning both the clinical and microbiological diagnosis of patients affected by SSTIs via an electronic case report form. All the cases included in our database, independently from their severity, have been managed by ID specialists joining the study while SSTIs from other wards/clinics have been excluded from this analysis. Here, we report the preliminary results of our study, referring to a 12-month period (October 2016–September 2017). During this period, the study population included 254 adult patients and a total of 291 SSTI diagnoses were posed, with 36 patients presenting more than one SSTIs. The type of infection diagnosed, the aetiological micro-organisms involved and some notes on their antimicrobial susceptibilities were collected and are reported herein. The enrichment of our registry is ongoing, but these preliminary results suggest that further analysis could soon provide useful information to better understand the national epidemiologic data and the current clinical management of SSTIs in Italy

Coulomb dissociation of O-16 into He-4 and C-12

We measured the Coulomb dissociation of O-16 into He-4 and C-12 within the FAIR Phase-0 program at GSI Helmholtzzentrum fur Schwerionenforschung Darmstadt, Germany. From this we will extract the photon dissociation cross section O-16(alpha,gamma)C-12, which is the time reversed reaction to C-12(alpha,gamma)O-16. With this indirect method, we aim to improve on the accuracy of the experimental data at lower energies than measured so far. The expected low cross section for the Coulomb dissociation reaction and close magnetic rigidity of beam and fragments demand a high precision measurement. Hence, new detector systems were built and radical changes to the (RB)-B-3 setup were necessary to cope with the high-intensity O-16 beam. All tracking detectors were designed to let the unreacted O-16 ions pass, while detecting the C-12 and He-4

Endoscopic cytology in biliary strictures. Personal experience

La diagnosi differenziale tra stenosi biliari maligne e benigne costituisce il momento fondamentale per il trattamento dei pazienti itterici. Lo scopo del nostro studio è quello di definire il ruolo della citologia, utilizzando la bile prelevata durante la colangiopancreatografia retrograda per via endoscopica (CPRE), nel definire la diagnosi di natura di una stenosi biliare. Pazienti e metodi. Questo studio retrospettivo è stato condotto su 67 pazienti consecutivi affetti da ittero ostruttivo ingravescente, sottoposti a ERCP ± PTE (endoscopia transepatica percutanea) + prelievo di bile + posizionamento di protesi biliare. Abbiamo identificato 21 stenosi ilari (31.3%), 17 stenosi della parte media della via principale (25.3%) e 28 stenosi del coledoco distale (41.4%). In un paziente (2%) la colangiografia non ha dimostrato alcuna stenosi ma abbiamo lo stesso prelevato la bile dopo il posizionamento di un sondino naso-biliare. Risultati. È stata possibile la diagnosi solo in 40 dei 65 pazienti (61.5%), mentre nei restanti 25 pazienti non è stata evidenziata cellularità nel prelievo di bile (38.5%). La presenza di neoplasia cefalopancreatica è stata esclusa (assenza di cellule atipiche) in 25 dei 40 esami diagnostici (62.5%) ma, durante il follow-up, solo 7 di questi 25 soggetti sono risultati affetti da stenosi benigna (veri negativi 28%), mentre i restanti 18 casi erano affetti da un tumore del distretto bilio-pancreatico (falsi negativi 72%). Nove su 14 pazienti con citologia positiva per carcinoma avevano un colangiocarcinoma (65%), 4 un cancro del pancreas (28%) e uno un carcinoma della papilla di Vater. Dei 25 campioni non diagnostici, 5 (20%) sono risultati benigni, 20 (80%) maligni. L’analisi statistica dei dati (test del chi-quadro) ci consente di affermare cha la citologia biliare, se diagnostica, è significativamente valida nell’evidenziare una neoplasia del tratto bilio-pancreatico (p < 0.05) anche se, considerando l’alto tasso di campioni non diagnostici, il suo ruolo appare molto ridimensionato (p = 0.09). Discussione. La citologia biliare esfoliativa di campioni ottenuti durante la CPRE è il metodo più facile e meno invasivo per la diagnosi di natura di una stenosi coledocica, ma per la sua bassa sensibilità (6-63%, secondo i dati della letteratura) non sembra particolarmente accurato; la dilatazione della stenosi prima del prelievo di bile sembra incrementare la sensibilità diagnostica e l’accuratezza dell’esame citologico. Conclusioni. Il prelievo di bile durante CPRE è un metodo sicuro che non aumenta la morbidità procedura-correlata, consente un orientamento diagnostico nel 75% circa dei casi e la sua sensibilità ed accuratezza sono migliorate dal prelievo dopo dilatazione della stenosi. Benché un risultato negativo non escluda una diagnosi di malignità, il risultato positivo va considerato diagnostico (valore predittivo positivo 100%)

Anastomosi meccaniche versus anastomosi manuali nella chirurgia del retto. Esperienza personale

Introduzione. La diffusione negli anni Ottanta delle suturatrici meccaniche ha modificato le abitudini dei chirurghi, sia determinando una riduzione dei tempi operatori nella chirurgia del colon-retto sia consentendo di eseguire resezioni ultrabasse del retto, tuttavia lasciando invariati i tassi di complicanze e ne ha anzi portato alla ribalta delle nuove. Scopo del lavoro è riportare la nostra esperienza in tema di suture meccaniche nelle anastomosi colo-rettali, con particolare attenzione alla identificazione dei fattori di rischio delle complicanze legate alla procedura. Pazientii e metodi. Da gennaio 2000 a gennaio 2006, presso la Sezione di Chirurgia Generale ad Indirizzo Toracico (Direttore: Prof. G. Modica) della Facoltà di Medicina e Chirurgia dell’Università di Palermo, sono state confezionate 26 anastomosi colo-rettali meccaniche e 11 colostomie terminali meccaniche dopo amputazione addominoperineale del retto: dodici pazienti sono stati sottoposti ad anastomosi termino-terminale colo-rettale bassa, 6 ad anastomosi termino-terminale colo-rettale ultrabassa, 1 ad anastomosi colo-anale, 7 ad anastomosi secondo Knight-Griffen per neoplasie del retto basso. Risultati. Due deiscenze anastomotiche (8%), 3 casi (12%) di emorragia precoce dalla rima anastomotica e un caso (4%) di stenosi dell’anastomosi a 12 mesi dall’intervento chirurgico. Non si è verificata mortalità procedura-correlata. Discussione. Dalla valutazione degli studi della letteratura emerge, secondo la scuola statunitense, l’assenza di differenze statisticamente significative tra sutura manuale e meccanica nelle anastomosi colorettale in termini di mortalità e morbilità (incidenza media, clinica e radiologica delle desicenze anastomotiche, stenosi anastomotiche, emorragie anastomotiche, reinterventi, infezione della ferita), del tempo impiegato a confezionare l’anastomosi e della degenza, mentre maggiore incidenza di deiscenza radiologica si registra nelle scuole europee per le suture manuali. Conclusioni. Ad oggi non esistono trial clinici che dimostrino la superiorità delle metodica con suturatrice meccanica rispetto alla sutura manuale nel confezionamento di una anastomosi tra colon e retto. L’avvento della sutura meccanica ha reso comunque possibile il confezionamento di anastomosi colo-rettali dopo resezione anteriore ultrabassa del retto in pazienti altrimenti candidati alla amputazione del retto per via addominoperineale secondo Miles, aumentando però l’incidenza di complicanze, quali la deiscenza e le stenosi, anche se in maniera non statisticamente significativ