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Internal abdominal hernias are a rare entity and may cause unexplained abdominal pain. This report concerns a 46 year old male patient, with a four year history of episodic colicky peristaltic abdominal pains, in whom a left paraduodenal hernia was found at surgical exploration after a negative diagnostic screening by ultrasound, CT and small bowel enema. Upon laparotomy the Authors found a left-sided paraduodenal hernia with an empty herniated sack. Repair of the hernial defect resulted in the complete and stable resolution of abdominal symptoms. The importance of considering paraduodenal hernias in the differential diagnosis of unexplained intermittent abdominal pain is discussed.

BACKGROUND AND AIM: Data on maximum resting pressure (MRP) and maximum squeeze pressure (MSP) changes after hemorrhoidectomy are not univocal and follow-up of patients undergoing surgery is mostly short-lived. The aim of this study was to prospectively examine during 1-year follow-up the long-term manometric results of MRP, MSP, and ultra slow wave activity (USWA) within a set of patients undergoing Milligan-Morgan hemorrhoidectomy as compared to healthy controls. MATERIALS AND METHODS: Twenty patients with hemorrhoids of third and fourth degree were enrolled and anorectal manometry was performed preoperatively, on the 5th day, and after 1, 6, and 12 months after surgery. RESULTS: On the 5th and 30th day after hemorrhoidectomy, USWA was slightly increased as compared to preoperative status. Six and 12 months after surgery, patients with USWA were significantly less in comparison to preoperative assessment without differences with healthy subjects. After surgery, MSP values were not significantly different to baseline values. On the 5th postoperative day after hemorrhoidectomy, MRP was significantly greater than baseline preoperative values. Thirty days after surgery, MRP values were similar to those detected preoperatively, but still significantly increased as compared to healthy subjects. After 6 and 12 months, MRP values were significantly lower than those detected during preoperative phase and comparable to healthy subjects. CONCLUSIONS: Our data support that Milligan-Morgan hemorrhoidectomy induces a complete resolution of typical manometric alterations of disease and that the excision of anal cushions is responsible only for mild and transient alteration of anal continence.

A case of bilateral testicular lymphoma with involvement of skin and oropharynx was described. After a review of literature, the Authors underline the clinical features focusing the diagnostic approaches and the therapeutics options.

PURPOSE: The maximum resting pressure in the anal canal is greatly raised after hemorrhoidectomy. This increase is likely to be the cause of postoperative pain, which is still the most troublesome early problem after hemorrhoidectomy. This study was designed to compare, after hemorrhoidectomy, the effects of intrasphincter injection of botulinum toxin vs. application of glyceryl trinitrate ointment in improving wound heating and reducing postoperative pain at rest or during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 40 days after hemorrhoidectomy. One group received one injection containing 20 IU of botulinum toxin, whereas the other an application of 300 mg of 0.2 percent glyceryl trinitrate ointment three times daily for 30 days. RESULTS: Five days after hemorrhoidectomy, maximum resting pressure was significantly reduced compared with baseline values in both groups (85 +/- 15 vs. 68 +/- 11 mmHg for the group treated with botulinum toxin, 87 +/- 11 vs. 78 +/- 11 mniHg for the group treated with glyceryl trinitrate ointment). Overall analysis of postoperative pain at rest showed a significant reduction in the botulinum toxin group vs. glyceryl trinitrate group, whereas pain during defecation and time of healing were similar. Adverse effects, such as headaches, were observed only in the glyceryl trinitrate group. Forty days after hemorrhoidectomy in the glyceryl trinitrate group, maximum resting pressure values were similar to preoperative ones, whereas the values were still reduced in the botulinum toxin group. CONCLUSIONS: A single intrasphincter injection of botulinum toxin was more effective and safer than repeated applications of glyceryl trinitrate in reducing early postoperative pain at rest but not during defecation.

Knowing the dynamics of growth factor and cytokine secretion within the site of a surgical operation is important, as they play a crucial role in the pathophysiology of wound healing and are a target for modifying the repair response. The aim of this study was to evaluate the production of several cytokines and growth factors in the drainage wound fluid from patients undergoing incisional hernia repair: namely, interleukin (IL)-6, IL-10, IL-1alpha, IL-1 ra, interferon-gamma, vascular endothelial growth factors and basic fibroblast growth factor. Ten female patients with abdominal midline incisional hernia undergoing surgical repair were included in this study. In all cases, a closed-suction drain was inserted in the wound below the fascia and removed on postoperative day 4. Wound fluid was collected on postoperative days 1-4 and the amount was recorded each time. Growth factors and cytokines production was evaluated as the whole amount produced over a 24-hour period. In all patients, the amount of drain fluid from surgical wounds was more copious the first day after surgery, it decreased significantly afterward. The presence of all cytokines was highest on postoperative day 1, decreasing over the following days. More specifically, the production of IL-1 ra, IL-6, IL-1alpha, and IL-10 on postoperative day 1 fell sharply on postoperative days 3 and 4, whereas, after an initial reduction, interferon-gamma showed an increase from day 2 onward. Vascular endothelial-derived growth factor production increased progressively after the operation reaching statistical significance only on day 4. As for basic fibroblast growth factor, it showed an opposite pattern: it was higher on postoperative day 1 decreasing thereafter. This analysis of cytokine and growth factor production in the drain fluid will lead us to a better evaluation of the events that follow a surgical wound and to a better understanding of the healing process.

PURPOSE: Hemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of the internal sphincter seems to play in important role in the origin of pain. This study was designed to evaluate the effectiveness of intrasphincter injection of botulinum toxin after hemaorrhoidectomy in reducing the maximum testing pressure of the anal canal, accelerating wound healing, and decreasing postoperative pain when resting and during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 30 days afterward ill all patients undergoing Milligan-Morgan hemorrhoidectomy. One group received an injection of 0.4 ml of saline into the internal anal sphincter, the other group were injected with 0.4 nil of solution containing 20 Units of botulinum toxin. RESULTS: After five days from hemorrhoidectomy, maximum resting pressure decreased in the group injected with botulinum toxin and increased in the placebo group). The time of healing and postoperative pain when resting and during defecation significantly decreased in the group treated with an injection of botulinum toxin. CONCLUSIONS: Botulinum toxin injection into internal anal sphincter after hemorrhoidectomy is effective in reducing rnaximum resting pressure, time of healing, and postoperative pain both on resting and (hiring defecation in absence of complications or side effects.

Metastases to the skin complicated by enterocutaneous fistula are a rare event in gynecological malignancies. We present the case of a 70-year-old woman with uterine cervix carcinoma metastatic to the skin and treated with surgery and radiotherapy. The last relapse to the skin was complicated by the formation of an enterocutaneous fistula. This low-output fistula was treated with surgery and adequate supportive care. The treatment of enterocutaneous fistulas may be either invasive (surgical resection, surgical repair with corrective procedures or with myocutaneous flaps, colonic and/or urinary diversion, endoscopic treatments with metallic stents) or conservative (skin care and local disinfection, pouching of secretions, control of nutrition and electrolytes, TPN, antisecretory treatment with scopolamine or octreotide, and control of psychological conditions). Enterocutaneous fistulas associated with skin metastases are not commonly reported in the literature and may be successfully treated with surgery and supportive care in patients with good performance status and no evidence of further metastatic disease.

PURPOSE: The maximum resting pressure in the anal canal is greatly raised after hemorrhoidectomy. This increase is likely to be the cause of postoperative pain, which is still the most troublesome early problem after hemorrhoidectomy. This study was designed to compare, after hemorrhoidectomy, the effects of intrasphincter injection of botulinum toxin vs. application of glyceryl trinitrate ointment in improving wound healing and reducing postoperative pain at rest or during defecation. METHODS: Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 40 days after hemorrhoidectomy. One group received one injection containing 20 IU of botulinum toxin, whereas the other an application of 300 mg of 0.2 percent glyceryl trinitrate ointment three times daily for 30 days. RESULTS: Five days after hemorrhoidectomy, maximum resting pressure was significantly reduced compared with baseline values in both groups (85 +/- 15 vs. 68 +/- 11 mmHg for the group treated with botulinum toxin, 87 +/- 11 vs. 78 +/- 11 mmHg for the group treated with glyceryl trinitrate ointment). Overall analysis of postoperative pain at rest showed a significant reduction in the botulinum toxin group vs. glyceryl trinitrate group, whereas pain during defecation and time of healing were similar. Adverse effects, such as headaches, were observed only in the glyceryl trinitrate group. Forty days after hemorrhoidectomy in the glyceryl trinitrate group, maximum resting pressure values were similar to preoperative ones, whereas the values were still reduced in the botulinum toxin group. CONCLUSIONS: A single intrasphincter injection of botulinum toxin was more effective and safer than repeated applications of glyceryl trinitrate in reducing early postoperative pain at rest but not during defecation.

BACKGROUND AND AIM: Data on maximum resting pressure (MRP) and maximum squeeze pressure (MSP) changes after hemorrhoidectomy are not univocal and follow-up of patients undergoing surgery is mostly short-lived. The aim of this study was to prospectively examine during 1-year follow-up the long-term manometric results of MRP, MSP, and ultra slow wave activity (USWA) within a set of patients undergoing Milligan-Morgan hemorrhoidectomy as compared to healthy controls. MATERIALS AND METHODS: Twenty patients with hemorrhoids of third and fourth degree were enrolled and anorectal manometry was performed preoperatively, on the 5th day, and after 1, 6, and 12 months after surgery. RESULTS: On the 5th and 30th day after hemorrhoidectomy, USWA was slightly increased as compared to preoperative status. Six and 12 months after surgery, patients with USWA were significantly less in comparison to preoperative assessment without differences with healthy subjects. After surgery, MSP values were not significantly different to baseline values. On the 5th postoperative day after hemorrhoidectomy, MRP was significantly greater than baseline preoperative values. Thirty days after surgery, MRP values were similar to those detected preoperatively, but still significantly increased as compared to healthy subjects. After 6 and 12 months, MRP values were significantly lower than those detected during preoperative phase and comparable to healthy subjects. CONCLUSIONS: Our data support that Milligan-Morgan hemorrhoidectomy induces a complete resolution of typical manometric alterations of disease and that the excision of anal cushions is responsible only for mild and transient alteration of anal continence.

The aim of the study was to evaluate whether topical application of 0.2% glyceryl trinitrate ointment could reduce post-haemorrhoidectomy healing time and pain both at rest and during defecation. Thirty patients with grade III and IV haemorrhoids were included in the study and divided into two groups. All patients underwent Milligan-Morgan haemorrhoidectomy, and anorectal manometry was performed before surgery and after 5 and 30 days. In one group a placebo ointment was applied to the perianal wounds, while in the other group a 0.2% glyceryl trinitrate ointment was used. Maximum resting pressure was reduced in the glyceryl trinitrate group and increased in the placebo group after 5 days. Postoperative pain both at rest and during defecation, and the time to healing and return to normal activity were significantly reduced in the glyceryl trinitrate group, whilst analgesic consumption was similar. An elevated incidence of headache was observed In the glyceryl trinitrate group. Topical application of glyceryl trinitrate was effective in reducing postoperative pain and healing time, but the substantial incidence of side effects may limit its extensive use.

Background The aim of this study was to evaluate changes in the production of some cytokines (interleukins [ILs]-6, -10, -1, and -1ra), vascular endothelial growth factor, and beta-fibroblast growth factor after polypropylene mesh implantation. Methods Twenty female patients were divided into 2 groups. In 1 group, hernia repair was performed with conventional sutures (CR), whereas in the other group polypropylene mesh (MR) was used. Growth factors and cytokines production was analyzed in wound drain fluids based on the amount produced during 24 hours. Results IL-1 increased substantially in MR patients on postoperative days 1 and 2. IL1-ra and IL-10 production was always significantly higher in CR patients. IL-6 production did not show any considerable difference between the 2 groups. Vascular endothelial growth factor production was significantly higher in the MR than the CR group at all time points, whereas beta-fibroblast growth factor production was higher in the MR than the CR group only on postoperative day 1. Comments Our data suggest that different surgical procedures induce various levels of inflammation and that implantation of prostheses significantly stimulates the inflammatory response.

The purpose of this study was to assess the modifications of interleukin (IL)-6, C-reactive protein (CRP), leukocytes and fibrinogen after implantation of polypropylene mesh.Thirty-six patients were included in this study and divided into two groups. To the first group were allocated patients affected by inguinal hernia and undergoing conventional repair (subgroup Ia) or hernioplasty with 40-cm(2) polypropylene mesh (subgroup Ib). To the second group were allocated patients affected by incisional hernia and undergoing conventional repair (subgroup IIa) or incisional hernia repair with 400-cm(2) polypropylene mesh (subgroup IIb). Peripheral venous blood samples were collected 24 h before surgery and then 6, 24, 48 and 168 h postoperatively.We present evidence that serum levels of IL-6, CRP, leukocytes and fibrinogen were significantly increased postoperatively in all subgroups compared with their baseline values. In particular, the production of inflammatory mediators was higher in subgroups Ib vs Ia and IIb vs IIa. Comparing the entities of the inflammatory responses among various groups we found that it was clear that they were similar in subgroups Ib and IIa, and that the highest were in subgroup IIb and the lowest in subgroup Ia.The data show that conventional inguinal and incisional hernia repair induces an inflammatory response, which is smaller than that observed if both operations are carried out with polypropylene meshes. Furthermore, the results suggest that a larger mesh is associated with a higher production of inflammation mediators.

Background: Postoperative pain associated with Milligan Morgan haemorrhoidectomy (MMIf) remains problematic. Most patients complaint a severe pain on defecation and in the 1st postoperative week because of secondary infection a fid sphincter spasm. We studied the effect of metronida zole, lactulose and glyceryl-trinitrate on pain after MMH. Method: Thirty patients were randomly assigned to two groups. The 1st received a treatment with oral laxative (lac- tulose 66,7%) metronidazole and a topical glyceryl-trinitrate ointment at 0,2% both pre and postoperative; the 2nd received a placebo at the same dosage. The amount of pain in the 1st week and at the time of two defecation, postoperative analgesic requirement ana time to return to normal activities were documented. Results: A significant differences in the score pain on 2nd and 3rd day and on the 1st two defecation were observed among group. Analgesic consumption was highest in the pla-cebo group. Conclusion: The treatment with lactulose, metronidazole and topic glyceryl-trinitrate in patients undergoing MMH, seems to reduce secondary pain and increase patients satisfaction and earlier return to work with improvement of cost and benefit.