Physical exercise in asthma adolescents: a concept review

Background: Asthma is a frequent pathological condition during childhood and adolescence. Young asthmatics demonstrate decreased aptitude for physical activity and a limited exercise capacity. Lower hospitalisation rates, reduced school absenteeism, fewer medical examinations, and limited use of bronchodilators have been documented in children and adolescents with bronchial asthma who engage in physical exercise regularly. Structured physical exercise protocols should be encouraged as they can work as a synergistic therapeutic option in addition to regular pharmacologic treatment. This article outlines the most suitable exercise training techniques for young patients with bronchial asthma and their effects on health status.

Familial Idiopathic Pan-Colonic Varices Found Incidentally in a Young Patient with a Hepatic Flexure Tumor

Patient: Male, 24-year-old

Final Diagnosis: Colon cancer

Symptoms: —

Medication: —

Clinical Procedure: Laparoscopic right hemi-colectomy

Specialty: Surgery

Disseminated intestinal basidiobolomycosis with mycotic aneurysm mimicking obstructing colon cancer

Basidiobolomycosis is a rare fungal infection that may affect the gastrointestinal tract. It is caused by Basidiobolus ranarum and less than 80 cases have been reported in the literature. The incidence seems to be higher in the Middle East and in particular Saudi Arabia where most cases are diagnosed in the south-western region. An 18-year-old woman presented to the emergency department with an obstructing caecal mass initially suspected to be malignant. Surgical resection was complicated by bowel perforation, histology and cultures confirmed basidiobolomycosis infection. The postoperative course was complicated by an enterocutaneous fistula, fungal intra-abdominal abscesses, liver and lung abscesses, formation of mycotic hepatic artery aneurysm and meningoencephalitis. The patient eventually expired due to sepsis despite aggressive treatment. Diagnosis and management of such rare cases are very challenging and require a multidisciplinary approach. Complications are common and associated with a high mortality.

A Rare Case of Adult-Onset Rectosigmoid Hypoganglionosis

Patient: Male, 20

Final Diagnosis: Rectosigmoid hypoganglionosis

Symptoms: Severe abdominal pain • obstipation • vomiting • shortness of breath • palpitations

Medication: —

Clinical Procedure: Hartmann’s procedure

Specialty: Surgery

Locally Advanced Breast Cancer in the Elderly: A Major Challenge Requiring Effective and Appropriate Treatment

Aims and background

Breast cancer is the most common tumor in women. As the population above 65 years increases, breast cancer will be a more substantial problem for elderly patients. This work reports our experience in the management of stage III and IV locally advanced breast cancer.

Methods

Nineteen patients over 65 years of age (mean, 70.3 years) with stage III and IV breast cancers, treated between 1990 and 2000, are considered. The management and outcome are evaluated.

Results

Nine patients had stage IIIA breast cancer, 7 stage IIIB and 3 stage IV. Sixteen underwent Madden mastectomy and 3 simple mastectomy. Patients at stage HIB and 1 patient at stage IV with T4 tumor received neo-adjuvant chemotherapy. There were no significant postoperative complications. Sixteen patients were given tamoxifen and 10 patients adjuvant chemotherapy. Patients were followed for a median of 36.7 months (range, 6–72 months). In 8 patients with stage III disease, metastasis developed. Two patients had local recurrence of disease. Of the patients at stage IIIA, 6 were free from disease (one died from unrelated causes) and 3 had recurrent disease (2 died). Of the patients at stage IIIB, 2 are disease free and 5 had recurrent disease and died. Of the patients at stage IV, only one is alive.

Conclusions

Stage and individual characteristics of elderly women influence management. Patients should be managed adequately since most of them are fit enough to undergo treatment.

Laparoscopic-Assisted Altemeier's Procedure for Recurrent Strangulated Rectal Prolapse: A Case Report

Patient: Female, 39

Final Diagnosis: Recurrent strangulated rectal prolapse

Symptoms: Chronic constipation • painful rectal mass • irreducible rectal prolapse

Medication: —

Clinical Procedure: Operation

Specialty: Surgery

Robotic surgery vs conventional laparoscopy for the treatment of rectal cancer: Review of the literature

Laparoscopic surgery has established itself as a safe and effective alternative to open surgery for the treatment of colorectal cancer. However, laparoscopic resection of rectal cancer, and in particular of the lower rectum, remains challenging in view of the limitations of operating in the confined pelvic space, limited movement of instruments with fixed tips, assistant-dependant two-dimensional view, easy camera fogging, and poor ergonomics. The introduction of robotic surgery and its application in particular to pelvic surgery, has potentially resolved many of these issues. To define the role of robotic surgery in total mesorectal excision for rectal cancer, a review of the current literature was performed using PubMed, Embase, Cochrane Library, and Google databases, identifying clinical trials comparing short-term outcomes of conventional laparoscopic total mesorectal excision with the robotic approach. Robotic surgery for rectal cancer is a safe alternative to conventional laparoscopy. However, randomised trials are needed to clearly establish its role.

Diagnosis and management of fetal ductus arteriosus constriction-closure

Pathognomonic features of in utero premature restriction/closure of the ductus arteriosus (DA) are increased right ventricular afterload, impaired right ventricular function, and consequently tricuspid regurgitation and right heart dilation. The most common reason for constriction-closure of DA is maternal administration of non-steroidal anti-inflammatory drugs (NSAIDs) during the 3rd trimester of gestation. The idiopathic form is a rare event and, maybe, an underestimated abnormality that, if it is not promptly recognized, may result in severe fetal-neonatal compromise. We describe a case of a 38-year-old woman presenting at 34+0 weeks of gestation with a normally grown male fetus whose fetal echocardiography had shown right ventricular hypertrophy, a tortuous S-shaped DA and a significant pulmonary hyperflow. All signs were consistent of an idiopathic severe constriction of DA with a significant fetal cardiac involvement. The patient was admitted to a tertiary care center equipped with Neonatal Intensive Care Unit (NICU), and delivered by cesarean section at 34+4 weeks with a good maternal and neonatal outcome. Based on our experience and a review of the Literature we propose a management algorithm to use when dealing with preterm or early term pregnancy complicated by this fetal hemodynamic malfunction.

Three-dimensional dynamics of a fermionic Mott wedding-cake in clean and disordered optical lattices

Non-equilibrium quantum phenomena are ubiquitous in nature. Yet, theoretical predictions on the real-time dynamics of many-body quantum systems remain formidably challenging, especially for high dimensions, strong interactions or disordered samples. Here we consider a notable paradigm of strongly correlated Fermi systems, the Mott phase of the Hubbard model, in a setup resembling ultracold-gases experiments. We study the three-dimensional expansion of a cloud into an optical lattice after removing the confining potential. We use time-dependent density-functional theory combined with dynamical mean-field theory, considering interactions below and above the Mott threshold, as well as disorder effects. At strong coupling, we observe multiple timescales in the melting of the Mott wedding-cake structure, as the Mott plateau persist orders of magnitude longer than the band insulating core. We also show that disorder destabilises the Mott plateau and that, compared to a clean setup, localisation can decrease, creating an interesting dynamic crossover during the expansion.

Subhepatic appendicitis: a diagnostic dilemma

A middle-aged woman was admitted with recurrent episodes of ill-defined right-sided abdominal pain, more prominent in the right upper quadrant. Surgical history revealed a laparoscopic cholecystectomy, 1 month prior, for gallstones that were thought to be the cause of her symptoms. However, she continued to experience similar pain with exacerbation leading to readmission. Blood tests revealed increased inflammatory markers and an ultrasound scan showed a tubular hypoechoic structure between her right kidney and liver corresponding to the area of maximal tenderness. A diagnostic laparoscopy was performed and a subhepatic inflammatory mass of appendicular origin was found. This required mobilisation of the right colon and appendicectomy. The patient made an uneventful recovery after being readmitted for an ileus treated conservatively. Histology revealed acute appendicitis with mucosal ulceration.

A novel approach to management of a sacral defect in ileal pouch-sacral fistula

Fistula formation after restorative proctocolectomy poses a challenge to the surgeon and sometimes can lead to the excision of the pouch. While pouch-vaginal fistulas are more common, pouch-sacral fistulas are a rare event and treatment is still controversial. The authors report a case of pouch-sacral fistula which was treated successfully with a novel approach comprising pouch revision, debridement of sacrum and placement of a human acellular dermal matrix (Alloderm) mesh to patch the residual large sacral defect. This is the first report of the use of Alloderm under this rare condition.

Time-dependent density-functional theory meets dynamical mean-field theory: real-time dynamics for the 3D Hubbard model

We introduce a new class of exchange-correlation potentials for a static and time-dependent density-functional theory of strongly correlated systems in 3D. The potentials are obtained via dynamical mean-field theory and, for strong enough interactions, exhibit a discontinuity at half-filling density, a signature of the Mott transition. For time-dependent perturbations, the dynamics is described in the adiabatic local density approximation. Results from the new scheme compare very favorably to exact ones in clusters. As an application, we study Bloch oscillations in the 3D Hubbard model.

Minimally invasive colectomy for Crohn's colitis: a single institution experience

BACKGROUND

Minimally invasive surgery for Crohn's ileocolitis is well established but few data exist regarding laparoscopic techniques for Crohn's colitis. We aimed to describe outcomes associated with minimally invasive surgery for Crohn's colitis, including predictors of conversion to laparotomy and postoperative complications.

METHODS

We identified all Crohn's patients who underwent minimal invasive colectomy at our institution from 1997-2008. Data represent frequency (proportion) or median (interquartile range). Multivariate regression identified factors associated with conversion and 30-day complications (odds ratio [95% confidence interval]).

RESULTS

Over 11 years we identified 92 patients, median age 40 (26-51) years, body mass index (BMI) 22.9 (19.3-26.4) kg/m(2); 61% were women. Median Crohn's duration was 6.5 (4-15) years, 11% had prior intestinal resection; medications included immunomodulators (62%), corticosteroids (54%), infliximab (35%). Forty-three cases (47%) were total colectomy, 17 (18%) subtotal colectomy, 32 (35%) were segmental. Straight laparoscopy was used in 57%; 43% were hand-assisted. Median operative time was 248 (190-292) minutes. There were 15 (16%) conversions; only small bowel disease predicted conversion (OR 7 [1.6-35]). Conversion was not associated with increased length of stay or with postoperative complications. Overall postoperative length of stay was 5 (4-7) days. Short-term complications occurred in 34% with reoperation in 5: obstruction n = 3, anastomotic leak n = 2. Only perianal disease predicted complications (2.6 [1.0-6.6]). There was no 30-day mortality.

CONCLUSIONS

Minimally invasive colectomy in patients with Crohn's colitis can be safely accomplished with reasonable operative times, conversion rates, and excellent postoperative outcomes.

Laparoscopic surgery for recurrent ileocolic Crohn's disease

BACKGROUND

Laparoscopic (LAP) surgery is increasingly performed for primary ileocolic Crohn's disease (CD), but its application in patients with recurrent ileocolic CD is less well described. Our aim was to assess whether or not a laparoscopic approach was safe, feasible, and conferred meaningful short-term benefits in this patient population.

METHODS

Patients undergoing LAP surgery for recurrent ileocolic CD at our institution from 1998-2008 were identified using a prospectively maintained database. Potential risk factors for conversion to open surgery and overall patient outcomes were assessed with univariate analysis.

RESULTS

Forty patients were identified, of which 30 (75%) were LAP-completed and 10 (25%) were LAP-converted. The groups did not differ with respect to clinicopathological features. LAP-converted patients were significantly more likely to require adhesiolysis than LAP-completed patients (100% versus 67%, P = 0.04). There was 1 intraoperative complication in a converted patient. LAP-converted patients had longer times to soft diet (4 versus 3 days, P = 0.03) and longer length of stay (7 versus 4 days, P = 0.003). The groups did not differ with respect to incidence of postoperative complications or frequency of readmission within 30 days. There was no mortality.

CONCLUSIONS

In up to 20% of patients with recurrent ileocolic, successful laparoscopic re-resection may be prevented by adhesions. Conversion increased the length of stay without increasing morbidity. We conclude that LAP surgery can be safely performed in selected patients with recurrent ileocolic CD and leads to short-term benefits.

[Electrocardiography by the neonatologist]

An electrocardiogram is a simple, non-invasive and inexpensive test, whose knowledge and interpretation should be an essential skill for neonatologists. It is a basic, easy and handy tool, very useful for the right approach to the child with suspected heart disease. The test provides important information on the heart rhythm and is essential to diagnose and therefore treat arrhythmic problems. It gives also information on the ventricular dimensions and volume and/or pressure overload of one or both ventricles. In case of malformative pathologies, the test enables to suspect the type of malformation. The aim of this report is to explain a normal electrocardiogram in a practical and simple way, through the definition of the necessary basic criteria to detect heart rate and rhythm, electrical axis of QRS complex, normal wave morphology in all leads and atrioventricular conduction (PR interval). Some basic information will also be provided on how to recognize a pathological electrocardiogram and heart rhythm disorders. Then we will use interactive methods to discuss some tracings through which it will be possible to reach a diagnostic orientation.

Actinomycosis of the sigmoid colon: A case report

Abdominal actinomycosis is a chronic suppurative infection caused by Actinomyces species. The ileo-cecal region is most commonly affected, while the left side of the colon is more rarely involved. The infection has a tendency to infiltrate adjacent tissues and is therefore rarely confined to a single organ. Presentation may vary from non specific symptoms and signs to an acute abdomen. A computed tomography scan is helpful in identifying the inflammatory process and the organs involved. It also allows visual guidance for percutaneous drainage of abscesses, thus aiding diagnosis. Culture is difficult because of the anaerobic character and slow growth of actinomycetes. Colonoscopy is usually normal, but may shows signs of external compression. Preoperative diagnosis is rare and is established only in less than 10% of cases. In uncomplicated disease, high dose antibiotic therapy is the mainstay of treatment. Surgery is often performed because of a difficulty in diagnosis. Surgery and antibiotics are required in the case of complicated disease. Combined medical and surgical treatment achieves a cure in about 90% of cases. The authors report a case of sigmoid actinomycosis where diagnosis was made from the histology, and a review of the literature is presented.

Minimally invasive total proctocolectomy with Brooke ileostomy for ulcerative colitis

BACKGROUND

Total proctocolectomy with Brooke ileostomy remains the optimal surgical procedure for select ulcerative colitis patients. However, few studies describe outcomes of minimally invasive total proctocolectomy with Brooke ileostomy. Our aim was to describe the safety and feasibility of these procedures by examining short-term (30-day) outcomes.

METHODS

Using a prospective database, we identified a cohort of patients who underwent laparoscopic total proctocolectomy with Brooke ileostomy at our institution from 2000-2007. Results are reported as median (range) or frequency (proportion).

RESULTS

Forty-four patients were included; age 65 years (54-73), 24 were male (55%), body mass index was 26.5 (22.1-30.2) kg/m(2). Colitis duration was 66 months (24-240), and 40% had prior surgery. The indication for surgery was refractory colitis (82%) and neoplasia (18%). Factors influencing choice of total proctocolectomy with permanent ileostomy were advanced age in 18 (41%), lifestyle in 13 (30%), medical comorbidities in 11 (25%), fecal incontinence in 10 (23%), oncologic reasons in 3 (6.8%), and obesity in 3 (6.8%). Twenty-three (52%) operations were hand-assisted laparoscopic surgery, 13 (30%) were laparoscopic-assisted, and 8 (18%) were "laparoscopic-incisionless" with transanal specimen extraction. Two laparoscopic-assisted cases (4.6%) were converted. Operative time was 329 (272-402) minutes, and length of stay 5 (4-6) days. Major post-operative complications occurred in 4 (9%); there were no perioperative mortalities.

CONCLUSIONS

Minimally invasive total proctocolectomy with Brooke ileostomy is a safe, feasible option for the surgical treatment of chronic ulcerative colitis, and is the procedure of choice for select patients.

Day hospital for incisional hernia repair: selection criteria

AIM

The authors report their experience with incisional hernia repair and set criteria for the safe performance of the procedure on a day hospital basis.

MATERIALS AND METHODS

From January 1994 to July 2005, 29 day hospital procedures for incisional hernia were performed under local anaesthesia. Selection criteria included: a hernial defect < 10 cm, a reducible hernial sac and negative history for obstructive symptoms. The repair was achieved with a polypropylene plug in defects < 3 cm and a double layer mesh in larger defects.

RESULTS

All patients were discharged within 7 hours of surgery. Postoperative pain was mild and required hospital analgesia in 30% of cases. Back at home analgesia was needed in only three patients (10%). Six patients (20%) developed a seroma that reabsorbed spontaneously. During a follow-up ranging 6 to 120 months (mean 75), no recurrence has been recorded.

CONCLUSIONS

In selected patients, incisional hernia repair as day hospital procedure is feasible, safe and absolutely effective. The use of polypropylene plugs and meshes accounts for a sound repair with low risk of complications.

[Recurrent varicose veins due to neovascularisation: can they be prevented?]

The authors analyse the problems of recurrent varicose veins on the basis of their own experience. The 5-year incidence of recurrent varicose veins ranges from 25 to 40% after internal saphenectomy. The recurrences should be classified in relation to the site and pathogenetic mechanism. The authors assess the effectiveness of a prevention method for sapheno-femoral stump recurrences. The study population consisted of 80 patients undergoing internal saphenectomy. In 34 (Group A) a traditional safenectomy was performed with short stripping, while in 46 (Group B) closure of the ostium with a flap of pectineal fascia was performed in order to prevent recurrences caused by neovascularisation. In Group A the recurrence rate was 27.1% as against 14.8% in Group B. Recurrences originating from the sapheno-femoral stump are mainly caused not only by an inadequate echo-colordoppler preoperative diagnosis and an inadequate or insufficient crossectomy, but also by neovascularisation. The pectineal flap method in our experience is a very simple, effective and complication-free technique to appreciably reduce recurrent varicose veins originating from the sapheno-femoral stump.

[Ultrasound tissue modifications after polypropylene prosthesis apposition in inguinal hernia]

Few studies have addressed the use of ultrasonography in the evaluation of abdominal hernia. In the present study ultrasonography was used to assess tissue modifications after apposition of a polypropylene prosthesis for inguinal hernia. Seventy-two patients submitted to calibrated inguinal hernioplasty (mesh and plugs) in local anaesthesia for inguinal hernia were studied by ultrasonography at 5 days, 1 and 3 months, and 1 year after the surgical intervention. The mesh presented as a small hyperechoic layer. In 50 patients (69.4%) a seroma was present above the mesh. The seroma was < 5 cc in 33 patients, between 5 and 10 cc in 6 patients, and > 10 cc in 11 patients. During the ultrasound examinations no recurrences were found and the mesh was not displaced. The seroma disappeared spontaneously between postoperative days 30 and 90 and was probably related to the size of the hernia and the number of plugs.

Adverse events after infusions of cryopreserved hematopoietic stem cells depend on non-mononuclear cells in the infused suspension and patient age

BACKGROUND

Adverse events (AE) represent a significant clinical problem after infusion of cryopreserved HPC. However, the factors playing a role in the pathogenesis have not yet been fully established.

METHODS

We prospectively collected data on AE that occurred with 179 HPC infusions performed on patients affected with hematologic neoplasm after high-dose chemotherapy. The stem cell source was hemopoietic progenitor cells aphaeresis (HPC-A) in 157 cases and hemopoietic progenitor cell BM (HPC-BM) in 22 cases. In all cases, an endotoxin-free DMSO was used.

RESULTS

One or more AE were registered in 51/179 infusions (28.6%). The frequency of AE was higher after HPC-A than after HPC-BM (31.3% vs. 4.5%; chi(2) test, P =0.008). With univariate logistic regression, other factors found important for AE were age (P =0.028), number of total nucleated cells infused per kilogram (P =0.002), volume per kilogram infused (P =0.057), volume of packed RBC (P =0.019), a content of non-mononuclear cells >0.5 x 10(8)/kg (<P =0.0001) and actual time of infusion (P =0.058). When all aforementioned factors were evaluated with a multivariate logistic regression, only age of patient (P =0.024) and a content of non-mononuclear cells >0.5 x 10(8)/kg (P =0.0003) remained significant. A significant correlation existed between reduction of cardiac frequency both with volume per kilogram infused (r =0.221, P =0.02) and actual time of infusion (r =0.269, P =0.005).

DISCUSSION

Cardiovascular changes are influenced by volume per kilogram infused and by actual time of infusion, while non-cardiovascular AE are dependent on patient age and contamination by non-mononuclear cells in apheretic harvests.

Superficial parotidectomy as first choice for parotid tumours

Parotid neoplasms represent 3% of all head and neck tumours, and most are benign. Malignant tumours account for 14-25% of cases. Surgery is the treatment of choice, with options ranging from simple enucleation to radical parotidectomy. Sixteen patients presented with a history of a painless parotid lump. Diagnosis was achieved by ultrasound scan and MRI. Fifteen superficial parotidectomies and 1 nerve-sparing total parotidectomy were carried out. At histology, 10 pleomorphic adenomas, 4 Warthin's tumours, 1 lymphoepithelial cyst and 1 sebaceous adenocarcinoma were detected. In the single case of carcinoma, the 6 peri-glandular lymph nodes included in the specimen were metastasis-free. In 3 patients (20%) a transient paresis of the facial nerve was noted. The capsule appeared breached in only 1 case of pleomorphic adenoma. Four patients (26%) were diagnosed as suffering from Frey's syndrome. A salivary fistula was recorded in 2 patients (13%). During follow-up ranging from 3 to 96 months no tumour recurrence was recorded. Superficial parotidectomy seems to be the best choice of treatment for benign parotid tumours, since it allows complete excision of the tumour with sparing of the facial nerve. A radical procedure is, however, needed if malignancy is confirmed at frozen section.

Doppler-guided hemorrhoidal artery ligation: an alternative to hemorrhoidectomy

PURPOSE

Postoperative pain is the main adverse effect of formal hemorrhoidectomy. A new technique based on Doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery was introduced in 1995 as an alternative to hemorrhoidectomy. The authors report a preliminary experience with this procedure.

METHODS

The Doppler-guided hemorrhoidal artery ligation technique uses a special proctoscope bearing a Doppler transducer that allows identification and suture ligation of the hemorrhoidal arteries. Sixty-eight consecutive patients (mean age, 48 years; range, 21-74 years) with Grade 3 hemorrhoids were treated.

RESULTS

Intraoperative discomfort was measured by a visual analog scale (1-10) and resulted in a mean score of 2.3 (range, 1.3-2.8). Only 38 percent of patients required postoperative analgesia. Patients were examined at 1 week, 1 month, and 3 months and every 6 months thereafter. The mean follow-up was 11 (range, 3-18) months. Bleeding resolved in 91 percent of patients, pain in 73 percent, and prolapse in 94 percent. Complications were recorded in five patients and included persistent pain for more than two days in two patients (3 percent), swelling and thrombosis of one of the hemorrhoids in two patients (3 percent), and a secondary hemorrhage in one patient (1.5 percent).

CONCLUSION

Doppler-guided ligation of the hemorrhoidal artery is a safe and effective alternative to hemorrhoidectomy and is associated with minimal discomfort and low risk of complications.

Solitary hemangioma of the small intestine: an unusual cause of bleeding diagnosed at capsule endoscopy

Solitary small intestine hemangiomas are rare and usually present with overt bleeding or chronic anemia. Diagnosis is usually difficult because traditional imaging techniques often lack accuracy. Capsule endoscopy is a new diagnostic tool that has showed greater sensitivity than other methods to reveal causes of bleeding in the small intestine. A case of hemangioma of the ileum in a 13-year-old boy is presented. Capsule endoscopy allowed diagnosis and planning of surgical treatment.

[Femoral hernioplasty with a mesh plug]

Prosthetic repair of femoral hernias is now standard practice. The aim of the study was to evaluate the results obtained using different types of polypropylene plugs in relation to the different anatomic-surgical aspects of the hernia. Twenty-five femoral hernioplasties were performed, 3 with Gilbert's conical plug, 18 with a dart plug, and 4 with Lichtenstein's cylindrical plug. The functional rehabilitation was rapid, and there were no postoperative complications; over follow-up periods of 3-132 months no recurrences have been reported. The correct choice of plug in femoral hernioplasty makes for efficacy, safety and simplicity. The possibility of choosing among different types of plug in relation to the anatomical characteristics of the hernia provides the surgeon with the right degree of flexibility for achieving the best possible result.

Male breast cancer: report of 2 cases and review of the literature

Male breast cancer is rare and accounts for 1% of all breast cancers. The authors report two cases of male breast cancer at Stage III and review the literature. A Madden mastectomy with axillary clearance was performed. Patients were given adjuvant chemotherapy and started on tamoxifen. At one year follow-up the patients are alive and free from disease. Modified radical mastectomy is the preferred surgical approach for localized disease. Adjuvant hormonal therapy with tamoxifen is recommended as first-line treatment. Adjuvant chemotherapy has a role in node-positive cancer and locally advanced disease. Men should be made more aware of the disease and multicentric clinical trials encouraged to ensure an appropriate treatment on the basis of prospectively collected data.

The role of capsule endoscopy in the work-up of obscure gastrointestinal bleeding

OBJECTIVE

To evaluate the role of capsule endoscopy in the detection of causes of obscure gastrointestinal bleeding.

METHODS

Fifteen patients, nine males and six females, mean age 46 years (range 20-75 years), were investigated. All patients had undergone upper and lower gastrointestinal endoscopy with no evidence of causes of bleeding. Indication for capsule endoscopy was overt bleeding in 10 patients (eight with melaena and two with rectal bleeding) and anaemia in five patients.

RESULTS

Diagnosis was made in four out of 10 patients with overt bleeding (40%) and in four out of five (80%) in the group with anaemia. The overall detection rate was 53%. Of the eight patients with melaena, two had angiodysplasia, one showed a diffuse inflammation of the jejunum and ileum probably related to associated portal hypertension, and five had a normal examination. Of the two patients with rectal bleeding, one had a polyp in the terminal ileum and the other a normal examination. Of the five patients with anaemia, one had jejunal carcinoma, three had Crohn's disease and one had a normal endoscopy.

CONCLUSION

Wireless capsule endoscopy is safe, effective, non-invasive, and provides definitive diagnosis in about one-half of patients presenting with obscure gastrointestinal bleeding and previous negative endoscopic examinations.

Plug-technique for small incisional hernia

OBJECTIVE

The authors report their experience with a new prosthetic technique for the repair of incisional hernia defects smaller than 3 cm.

METHODS

From January 1995 to September 2002, 16 operations for small incisional hernias have been performed. Local anaesthesia was used in 12 out of 16 patients (75%). The repair was achieved by insertion of a polypropylene plug sutured to the margins of the hernial defect.

RESULTS

All patients were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in 25% of cases. Back at home analgesia was needed in only 1 patient. During a follow-up ranging 3 to 91 months (mean 46), no recurrence has been recorded.

CONCLUSION

The proposed technique allows a sound repair of small incisional hernias with minimal pain, quick rehabilitation and early return to unrestricted work.

Analogic evaluation of pain during inguinal hernioplasty under local anaesthesia

OBJECTIVE

The authors evaluate intraoperative pain in patients undergoing tension-free inguinal hernioplasty under local anaesthesia.

MATERIAL AND METHODS

One hundred and fourteen primary inguinal hernia repairs were carried out at the Department of General Surgery I of Catania University Polyclinic from January to September 2002. 2% Mepivacaine cloridrate was the local anesthetic of choice. Intraoperative pain was measured by a visual analog scale.

RESULTS

A mean analogic score of 1.9 (range 0-2.9) was obtained. Intraoperative complications were recorded only in 2 patients (1.7%). There was no operative mortality. All patients were up and about straightaway after surgery, had a light meal two hours later and were discharged within one day of operation.

CONCLUSIONS

Inguinal hernia repair under local anaesthesia is well tolerated and is associated with a low risk of complications.

[Inguinal hernia recurrence after prosthetic repair: our experience]

Inguinal hernia recurrence after prosthetic repair is a very rare clinical condition (1%), but it is probably underestimated and hard to resolve surgically. The authors reports their experience with 16 recurrent post-prosthetic inguinal hernias. A greater incidence of recurrence was noted in obese patients with concomitant chronic diseases (56%). Hernia recurrences following prosthetic repair are often asymptomatic. The use of Lichtenstein's plug technique yielded satisfactory results in terms of rehabilitation and incidence of recurrence and is also associated with a very low risk of complications.

[Organization of a day surgery unit for hernia]

The authors report their experience with the organisational aspects of minimal hospitalisation of patients undergoing surgical treatment for hernias of the abdominal wall. 1544 hernia repairs were carried out from January 1994 to March 2002; over 80% of these were performed on a day surgery basis. The organisation of a day surgery unit requires dedicated medical and nursing staff and also diagnostic imaging facilities that should be immediately available, though all this is not strictly necessary in a general surgery department. In conclusion, in addition to the organisational problems, inadequacy of the D.R.G. system in Italy is the primary obstacle to diffusion of the practice of ambulatory hernia repair.

[Tension-free prosthetic repair in the surgical treatment of epigastric hernia]

From November 1994 to June 2001, the authors have performed 16 operations for epigastric hernia. Local anaesthesia was used in 8 patients with small hernias, in the remaining 8 general anaesthesia was preferred. In defects smaller than 4 cm, the repair was achieved by insertion of a polypropylene dart plug sutured to the margins of the hernial defect. In larger defects a double layer mesh placed in the pre-peritoneum was used. All patients were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in 25% of cases and domiciliary analgesia in 1 patient only. During a follow-up ranging 3 to 79 months (mean 31.2), no recurrence has been recorded. The proposed technique is simple, safe and absolutely effective, allows immediate rehabilitation with a low risk of complications.

[Extraperitoneal prosthesis repair in the surgical treatment of inguinal hernias]

The authors analyse the current state of the art of the prosthetic repair of incisional hernia and the problems involved in positioning the prosthesis, comparing their own experience with the most recent literature. From January 1994 to June 2001, 50 patients were operated on for incisional hernia (28 males and 22 females); 12% had recurrent or re-recurrent incisional hernias. Defects smaller than 3 cm were repaired with a polypropylene plug; a double-layer polypropylene mesh placed in a preperitoneal position was used for defects measuring from 3 to 5 cm; in defects greater than 5 cm a double-layer mesh was placed behind the muscle layer. Fifteen patients were operated on under local anaesthesia. Only 22% required postoperative analgesia. The mean hospital stay was 3.95 days. Only 3 recurrences (6%) were recorded. On the basis of our experience it seems appropriate to repair incisional hernias when of small size, preferably under local anaesthesia, avoiding opening the hernia sac, using an extraperitoneal approach with an overlap technique that employs polypropylene.

[Plug-technique for umbilical hernia repair in the adult]

BACKGROUND

Umbilical hernia represents 6% of all abdominal wall hernias in the adult. Surgical repair should always be carried out due to possible occurrence of complications. Aim of this paper is to evaluate the efficacy of the plug-technique.

METHODS

From October 1995 to April 2000, the authors performed 21 operations for acquired umbilical hernia with a defect smaller than 4 cm. Local anesthesia was used and a light intravenous sedation added in particularly anxious patients. The repair was achieved by insertion of a polypropylene dart plug sutured to the margins of the hernial defect.

RESULTS

All patients were up and about straightaway and were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in only 19% of cases and domiciliary analgesia in 24%. During a follow-up ranging from 6 to 60 months (mean 30), only one recurrence has been recorded.

CONCLUSIONS

This tension-free technique allows immediate rehabilitation, with few complications and a low recurrence rate.

Retroperitoneal gas gangrene complicating elective inguinal hernia repair

Gas gangrene is a well recognised complication of contaminated military wounds. A case of Clostridial myonecrosis following elective inguinal hernia repair is described. The pathology, clinical features and management of this life-threatening condition are reviewed.

[Current approach in the treatment of desmoid tumors of the abdominal wall]

Desmoids of the abdominal wall are rare tumours with an incidence of 2-4 cases per million. From our experience which is reported here in detail (5 cases observed over the past 20 years), we draw the conclusion that the only completely reliable diagnosis is still histological, in spite of the use of ultrasound, CT scans and the new imaging possibilities afforded by NMR. After comprehensive excision of at least 2 cm of macroscopically healthy tissue from the tumour margins, reconstruction using prosthetic materials, such as Mersilene, PTFE or Prolene was performed. Neither radiotherapy nor chemotherapy were used, since there were doubts as to their usefulness. The functional and cosmetic results were satisfactory in all cases. Over follow-up periods ranging from 3 to 13 years, none of the patients has presented recurrences or incisional hernias.

[Tension-free lumbar hernioplasty]

The authors report a case of a 51 year-old woman with spontaneous Grynfeltt's hernia. Computerized tomography accurately displayed the anatomy of the lumbar region, thus aiding diagnosis and treatment. A double layer polypropylene mesh was used for the repair, placed in the pre peritoneum and sutured to the margins of the hernial defect avoiding muscles and fascias. The use of a double layer prosthesis and reduction of tension on the suture line allow a sound repair, with minimal postoperative pain and immediate resumption of daily activities.

rrn operons in Haemophilus parainfluenzae and mosaicism of conserved and species-specific sequences in the 16S-23S rDNA long spacer

The mosaic organisation of short-sequence boxes was analysed in the cloned and sequenced long ribosomal spacer (547 bp) of Haemophilus parainfluenzae GR. Comparison and alignment of both the long and the short spacer were performed in H. parainfluenzae and H. influenzae Rd. The long spacer contained two tRNA genes (tRNA(Ala) and tRNA(Ile)) which are highly homologous to the corresponding genes found in the spacers of other species, such as Haemophilus spp., Actinobacillus spp., and Plesiomonas shigelloides. At the 3' end of tRNA(Ala) a putative ribosomal spacer loop was found, showing a strong secondary structure. Pulsed field gel electrophoresis (PFGE) analysis after restriction of the genome of H. parainfluenzae GR with I-Ceu I and subsequent polymerase chain reaction (PCR) analysis of PFGE-separated DNA fragments demonstrated that the H. parainfluenzae genome contained six operons and that the long spacer was present in three copies of them. Two short DNA segments were identified as being species-specific, allowing us to design PCR primers which were useful in the molecular identification of H. parainfluenzae isolates.

[Inguinal hernioplasty with calibrated prosthesis (personal modification of the Trabucco technique]

From January 1994 to December 1997, the authors operated on 636 patients with primary inguinal hernia, using an original modification of Trabucco's tension-free and sutureless technique. The hernial defect is sized according to Gilbert's classification modified by Rutkow and Robbins and repaired with one or more plugs (up to four in the authors' experience) in relation to its extent. The posterior wall is reconstructed over the plugs encompassing the transversalis fascia and a wing of the plug superiorly and the iliopubic tract inferiorly. The double-layer polypropylene mesh is fashioned intraoperatively and the key-hole tailored to the variable distance between the spermatic cord and the pubic tubercle. All patients ambulated immediately after the operation, had a light meal two hours later and were discharged within one day of surgery. During a 3 months to 4 year follow-up only one recurrence has been recorded (0.16%). The proposed technique allows to perform a repair to measure ("calibrated") with minimal pain, immediate rehabilitation and early return to unrestricted activity.

Molecular epidemiology of enterococci with high-level resistance to aminoglycosides

DNA-based methodologies are considerably more powerful than other phenotype-based typing systems, providing a finer level of epidemiological discrimination, differentiating both closely and distantly related independent isolates that otherwise may appear as identical. In this study, plasmid analysis and pulsed-field gel electrophoresis were used to compare 28 isolates of Enterococci (respectively 13 strains of Enterococcus faecalis and 15 strains of Enterococcus faecium) with high-level resistance to aminoglycosides, isolated in Catania (Italy). Plasmid profile analysis resolved 20 different patterns among 24 plasmid harboring strains; many isolates showed one or two plasmids of the same size, but different plasmid content. Analysis of the PFGE-based RFLP patterns after SmaI digestion of genomic DNA resolved 26 different clones from 28 isolates: particularly, it resolved two different clones from three isolates showing identical plasmid profiles, and it identified as a single clone two isolates exhibiting different plasmid profiles. Thus, on the basis of our PFGE-based RFLP analysis data, we concluded that all the strains included in the study were genetically unrelated with two exceptions.

[Hernia repair with local anesthesia]

The authors report the results of their own personal experience with inguinal and femoral hernioplasties (424 cases) performed under loco-regional anaesthesia. This anaesthetic approach together with the use of prosthetic techniques (tension-free and suture-less) represent the "Gold Standard" in the surgical treatment of hernia. The absence of mortality, the remarkable reduction in terms of postoperative complications, days of hospitalization (one day surgery) represent outstanding advantages. The cooperation of the patient and the stress test at the end of the operation are further advantages of the proposed technique.