[Factors associated with ileal-pouch related fistulas in 100 consecutives patients who underwent restorative proctocolectomy].

The pouch-related fistulas range in literature from 2% to 16% and they can be cause of failure of the intervention of restorative proctocolectomy. Aim of this study was to examine factors associated with theirs development and to identify theirs possible etiology and pathogenesis. Retrospective study focusing on 100 consecutive patients who underwent restorative proctocolectomy with pouch-anal anastomosis (IPAA). Patients with fistula and patients without fistula have been identified and the fistula type, the time from surgery and the site relative to IPAA have been recorded. Patients' demographics, co-morbidity or related medical history, clinical indication for treatment, surgical method, histological diagnosis, length of follow-up, early and late postoperative complications have been reviewed, and data collected have been compared among the two groups through univariate analysis. The overall incidence of fistulas was of 10% (10 cases); 8 cases had pouch-vaginal fistulas, involving the distal tract of the vagina, and associated with pouch-perineal fistulas in 2 cases; 1 case had pouch-vulval fistula; 1 case had a complex pouch-perineal fistula. Three fistulas were precocious, all associated with an IPAA leak; 2 of these cases also had pelvic sepsis while the third had delayed diagnosis of Crohn s disease. Seven fistulas had a late development. Four fistulas occurred at the level of the IPAA; 5 fistulas were located below the IPAA, and 1 fistula originated above and below the IPAA. When the two groups of patients were compared we found that there was an higher percentage of perineal or anal disease (40.0% vs 2.2%; p <0.001), of extraintestinal manifestations of inflammatory bowel disease (IBD) (40.0% vs 3.3%, p <0.001), and of leak of the IPAA (40.0% vs 11.1%; p <0.05) in the group with fistula vs the group without fistula. A direct link with the leak of the IPAA appears in all the early fistulas, while the cryptoglandular infection was suggested as a possible cause of the late fistulas located below the IPAA; the association with the extraintestinal manifestations of IBD could show a correlation between the fistulas and an higher specific activity of the underlying chronic inflammatory disease

Recurrent Gallstone Ileus : case report and literature review

The gallstone ileus is a rare complication of cholelithiasis (2) and it represents the 1-4% of small intestine mechanical obstruction. This particular pathology, as described for the first time in 1654 by Bartolini, consists of mechanical obstruction of the bowel lumen by a gallstone. Usually the gallstone is wedged in the terminal ileum, even if unusual locations to duodenojejunal flexure(1-7) have been described. Clinically, gallstone ileus presents acute abdominal pain and vomiting. From a radiological point of view there is the pathognomonic triad composed of pneumobilia, small bowel obstruction and ectopic gallstone (6). The morbidity and mortality of this disease, remain very high, often because of misdiagnosis or delayed diagnosis (4). In fact, the average duration of symptoms is 6 days (range 2-14) with an average diagnostic delay of 3.5 days (range 1-10) (5). The choice between one-time surgical procedure and surgery at two times is often difficult: in literature there is no unique opinion on this. The majority of the authors prefers the enterolithotomia and cholecystectomy surgery with cholecysto-duodenal fistula repair; others indicate first the enterolithotomia surgery followed by cholecystectomy and fistula repair. We consider useful to present a clinical case that summarizes the diagnostic and therapeutic difficulties of gallstone ileus

Integrated multidisciplinary treatment of colorectal neoplasms

n this retrospective study, the modality and advantages of the multidisciplinary diagnostic work-up and therapy regarding colorectal neoplasm were analysed. Over the period 2004-2008, 63 patients underwent multidisciplinary treatment for colorectal cancer. All patients underwent surgery (laparoscopic/open). Exeresis was supplemented by adjuvant chemotherapy in those cases beyond IIA stage; all cases of extraperitoneal rectal and anal canal neoplasms plus one case of carcinoma of the transverse colon, initially inoperable, underwent neoadjuvant radiotherapy plus chemotherapy. The treatment was initiated approximately 3 weeks after the diagnosis. Fifty-four percent of patients with colonic and upper rectal neoplasms were given adjuvant chemotherapy, starting around 4 weeks after surgery. Exeresis was performed in those patients with extraperitoneal rectal and anal canal neoplasms (12.7%) about 6-8 weeks after they had completed neoadjuvant therapy. At the end of the treatment, 76% of the overall total numbers of patients were in good condition (follow-up 4-50 months). The remaining 24% suffered recurrences about 13 months after the treatment for colonic and upper rectal neoplasm, and 8 1/2 months after treatment for extraperitoneal rectal/anal canal neoplasms. Seventy-five percent of the recurring cases underwent treatment again, with 50% success; the others are still undergoing treatment. The best therapeutic results were obtained by programmed integration of the various diagnostic-therapeutic steps according to an algorithm which we elaborated to evaluate all types of neoplasm at any stage of illness