121 research outputs found
Ruolo della chirurgia nell’ occlusione intestinale nei pazienti affetti da malattia di Crohn.
No full textL’occlusione rappresenta la più frequente indicazione all’intervento chirurgico (30-40%), che, ogniqualvolta possibile, va eseguito in elezione o almeno in urgenza differita per ridurre l’incidenza delle complicanze postoperatorie
I pazienti che non rispondono alla terapia conservativa, con segni di sofferenza vascolare o di pericolo di incipiente perforazione, devono essere operati in urgenza. Un intervento in elezione trova giustificazione nei casi di ostruzione persistente nonostante una adeguata terapia medica, specialmente se si tratta di una stenosi di vecchia data con prevalente componente fibrotica.
In fase preoperatoria è utile un approfondimento diagnostico clinico, laboratoristico e strumentale. La TC e la RM consentono di escludere ascessi concomitanti, di precisare la localizzazione e l’estensione e di definire il grado di attività della malattia (lieve, moderata, severa); in caso di assenza di importanti segni di flogosi (> calprotectina, > vascolarizzazione e contrast enhancement) la chirurgia precoce è valida alternativa alla terapia medica.
Nei pazienti destinati alla chirurgia precoce è importante valutare la terapia in atto prima dell’evento occlusivo; gli steroidi > il rischio di complicanze postoperatorie e pertanto vanno scalati. I biologici, peraltro indicati quale terapia conservativa nei pazienti non destinati alla chirurgia immediata, determinerebbero un incremento delle complicanze postoperatorie (ma non delle infezioni).
L’intervento di scelta è la resezione. La ricostruzione del transito è di frequente protetta da una ileostomia. La concomitanza di un ascesso impone il drenaggio chirurgico o, preferibilmente, TC-guidato in fase di studio e di preparazione preoperatoria. Una stenosi, se raggiungibile dall’endoscopio, può essere trattata in maniera conservativa (dilatazione, endoprotesi).
L’anastomosi meccanica L-L a lume ampio è la migliore, poiché presenta bassi tassi di complicanze e forse di RPO, se confrontata con quella manuale.
Questo caso (paz giovane, plurioperata) illustra l’importanza di risparmiare quanto più possibile un intestino già resecato: è stato conservato l’ileo terminale, sede di riassorbimento attivo di Vit B 12 e di sali biliari, per evitare il conclamarsi della SBS. Attenzione è stata posta per evitare cul di sacchi, che, con la conseguente iperproliferazione batterica, aggraverebbero la SBS.
Le stricturoplastiche (Mikuliks, Finney, Taschieri, Fazio) sono riservate a pochi casi selezionati con stenosi del piccolo intestino
Surgical management of acute diverticulitis. An update based on our experience and literature data.
No full textAnn Ital Chir. 2019;90:432-441. Surgical management of acute diverticulitis. An update based on our experience and literature data. Fornaro R, Caristo G, De Rosa R, Ammirati CA, Oliva A, Batistotti P, Mascherini M, Frascio M. Abstractin English, Italian BACKGROUND: The treatment of acute diverticulitis is a matter of debate and has undergone significant changes. Currently the main focus of surgical treatment is a more conservative and less invasive management. AIMS AND METHODS: To focus the role of surgery in the treatment of acute diverticulitis, the Authors have conducted a review of the literature of the last two decades and have revised critically their own experience. RESULTS: The indications for elective surgery based on the number of episodes, the young age at diagnosis and the presence of risk factors such as immunosuppression, have to be overcome in favour of a more individual approach based on the severity of the disease. Similarly the presence of pneumoperitoneum is no longer a compelling indication for urgent surgery just as it was in the past. In the treatment of complicated diverticulitis with abscess (Hinchey I-II) is used more and more conservative treatments consisting of guided percutaneous drainage combined with antibiotics. Resection with primary anastomosis with or without diverting ileostomy is preferable to Hartmann's procedure in case of perforated diverticulitis with peritonitis (Hinchey III-IV), using the latter only in the case of comorbidities, severe sepsis, hemodynamic instability or longtime feculent peritonitis (Hinchey IV). Recently, laparoscopic peritoneal lavage was introduced in the treatment of diverticulitis. CONCLUSIONS: Thanks to the progress made in conservative and interventional treatment and laparoscopic surgery, an increasingly less invasive treatment is proposed in the management of acute diverticulitis. KEY WORDS: Acute diverticulitis, Laparoscopic surgery, Surgical treatment. PMID: 3181460
Recurrent Leiomyosarcoma of the Small Bowel: A Case Series
No full textLeiomyosarcoma is an extremely rare, small bowel neoplasm (2% of all gastrointestinal tumours). Early diagnosis is challenging due to the slow growth of the cancer. The biological behaviour of this group of tumours is aggressive, and the first-line treatment is surgical resection
Neurological complications in thyroid surgery: a surgical point of view on laryngeal nerves.
No full textThe cervical branches of the vagus nerve that are pertinent to endocrine surgery are the superior and the inferior laryngeal nerves: their anatomical course in the neck places them at risk during thyroid surgery. The external branch of the superior laryngeal nerve (EB) is at risk during thyroid surgery because of its close anatomical relationship with the superior thyroid vessels and the superior thyroid pole region. The rate of EB injury (which leads to the paralysis of the cricothyroid muscle) varies from 0 to 58%. The identification of the EB during surgery helps avoiding both an accidental transection and an excessive stretching. When the nerve is not identified,the ligation of superior thyroid artery branches close to the thyroid gland is suggested, as well as the abstention from an indiscriminate use of energy-based devices that might damage it. The inferior laryngeal nerve (RLN) runs in the tracheoesophageal groove toward the larynx, close to the posterior aspect of the thyroid. It is the main motor nerve of the intrinsic laryngeal muscles, and also provides sensory innervation to the larynx. Its injury finally causes the paralysis of the omolateral vocal cord and various sensory alterations: the symptoms range from mild to severe hoarseness, to acute airway obstruction and swallowing impairment. Permanent lesions of the RNL occur from 0.3 to 7% of cases, according to different factors. The surgeon must be aware of the possible anatomical variations of the nerve which should be actively searched for and identified. Visual control and gentle dissection of RLN are imperative. The use of intraoperative nerve monitoring has been safely applied but, at the moment, its impact in the incidence of RLN injuries has not been clarified. In conclusion, despite a thorough surgical technique and the use of intraoperative neuromonitoring, the incidence of neurological complications after thyroid surgery cannot be suppressed, but should be maintained in a low range
Surgical timing in the management of Crohn's disease in the era of biological drugs.
No full textBackground The indications and the timing for surgery are obviously related to the type of complications; but a key role, in choosing the most appropriate time to perform surgery, is played not only by factors related to patient but also by the evaluation of disease intrinsic characteristics:
stenosing/penetrating/inflammatory disease, disease activity, extension, prevalent localization and the response to medical therapy. Methods The authors analyzed the literature of the past two decades by integrating it with their personal experience. The authors have paid attention above all to Crohn’s disease management. Results Advances in medical therapy over the past two decades have substantially altered the management of patients with IBD. The introduction of more aggressive regimens (top down strategy) resulted in a change of surgery, which is no longer seen as “a last resort”, to be reserved for the treatment of a longstanding disease with more serious complications, but should also be seen as “early surgery”, able to induce remissions faster and perhaps more durable, at least in the short to medium term. It is logical to wonder whether this is also a result of a change in the natural history of the disease under the influence of new therapies. Biological drugs have proved to be able to induce remission (60%), to keep it free from steroids for short-medium periods and to return the integrity of the mucosa, which is important to control the disease. Mucosal healing leads to a decrease of complications’ rate, fewer hospitalizations and thus a possible reduction in the rate of surgical interventions. There are
still doubts about the real reduction of the need for surgery. Biological drugs have positive response only in 60% of cases and it is also possible to develop antibody reactions and resistance to the drug (10%). In addition, the disease often presents as a stenosing form, for which biologics are little or no effective and so surgery, even early, is required. Prolonged periods of remission are achieved only in 15% of cases. Borrowing the positive effects of antiTNF in the treatment of rheumatic diseases, we wondered if the use of biologics in Crohn’s disease may result in a change of the natural history of the disease. This problem remains unsolved. Doubts also remain about the actual reduction in the rate of hospitalization and in the need for surgery. Conflicting data emerge from randomized trials and observational studies. Conclusions There is still no evidence of a real reduction in the rate of interventions. Even today, the ideal treatment of Crohn’s disease is an unclear argument. Surgery plays a leading role and should not be considered only as “a last resort”; early surgery may indeed allow faster and more lasting remission
Infections in patients with inflammatory bowel disease
No full textBackground/aim: Inflammatory bowel diseases (IBD) are a group of conditions characterized by chronic inflammation of all or part of the digestive tract and primarily includes Ulcerative Colitis (UC) and Crohn's Disease (CD). This review has as target to summarize the complicated correlation between IBD and infections, which can affect patients' quality of life and increase substantially morbidity and mortality rates.
Results: Scientific evidence in recent years shows a growing recognition of the phenomenon although the association between these two aspects is not definitively clear. Despite the fact that our understanding of this linkage is still incomplete, it is easily deducible that infections can start whether it be the onset or the relapse of IBD. In addition to this, the course of the disease predisposes the patient to numerous infections caused by the drugs used to treat IBD and this also raises the risk of infection complications.
Conclusions: Clinical trials have demonstrated that the combined use of immunomodulating agents may increase the risk of new infections. The infections might be intensified by an insufficient vaccination of adults with IBD. Physicians have to be aware of these risks and try to attenuate and treat them properly
Sleeve gastrectomy may double the risk of esophageal adenocarcinoma in morbidly obese patients
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