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Background Despite the improvement of medical therapies, nearly half of patients with Crohn’s disease require surgery within 10 years after diagnosis. However, intestinal resection is not curative and recurrence may occur. Aims To evaluate post-surgical outcomes for patients with Crohn’s disease in a large monocentric cohort, and to identify variables associated with clinical and surgical relapse. Methods Patients with Crohn’s disease who had surgery for ileal and colonic Crohn’s disease between 2004 and 2016 and on at least one-year follow-up following surgery were included. Results One hundred ninety-three patients were included in the study. Crohn’s disease recurrence concerned 53% of patients after a median 56-month (6–158) follow-up and 29% of patients required a second surgical intervention. At logistic regression analysis, active smoking and young age at diagnosis were identified as independent risk factor for post-surgical relapse (p = 0.01), while colonic or ileocolonic resection was recognized as a risk factor for surgical Crohn’s disease relapse (p = 0.003). Conclusions Post-surgery recurrence is frequent for patients with Crohn’s disease. Active smoking and young age at diagnosis are risk factors for Crohn’s disease recurrence. As compared with patients undergoing small-bowel surgery, patients with colonic resection are proner to relapse requiring a second surgical intervention.

Tumors of the angle of Treitz are a rare entity. Only 3%-5% of gastrointestinal stromal tumors (GISTs) occur at the level of the duodenum, and their location at the duodenojejunal junction is very uncommon. Surgery is the treatment of choice, while adjuvant medical therapy is used on the basis of the degree of radicality of the excision and the tumor's proliferative profile. These factors primarily influence the prognosis. Due to the frailty of the vascular viability of the left duodenum, which can be injured during surgery, it is generally recommended to perform digestive reconstruction at the level of the right portion of the duodenum. We here report the case of a patient with a large GIST located at the duodenojejunal junction behind the ligament of Treitz. We found reconstructive digestive anastomosis at the level of the third part of the duodenum to be a safe procedure.

Bouveret's syndrome is a gastric outlet obstruction due to a gallstone impacted in the duodenal lumen or in the stomach via a bilioenteric fistula. It's the rarest form of gallstone ileus, with few cases reported in medical literature. Typically, this condition affects elderly people and causes high morbidity and mortality rates.We present a review of the published cases of Bouveret's syndrome between 2006, year of publication of the largest case series, and 2015 with particular regard to the operative management and treatment options. Two demanding cases of Bouveret's syndrome reported in our Hospital are also described.Bouveret's syndrome is a rare clinical condition and data reported in medical literature only derive from single case reports and case series. Therefore no clear management indications have been ruled out and treatment options are still matter of debate.Bouveret's syndrome is a rare clinical entity with a challenging operative management. Surgical or endoscopic treatments should be tailored on patient medical conditions and clinical presentation.Bouveret's Syndrome, Cholelithiasis, Gallstone Ileus, Gastric Outlet Obstruction, Intestinal Obstruction.La sindrome di Bouveret è una rara forma di ileo biliare dovuta ad un calcolo che ostruisce il lume duodenale. Tale condizione clinica si manifesta generalmente nelle persone anziane con una storia anamnestica caratterizzata da plurimi episodi di colecistite acuta. Il calcolo solitamente migra nel lume duodenale attraverso una fistola colecisto-duodenale. La fistola fra la colecisti e la parete del duodeno si manifesta quale conseguenza di una lesione da decubito sostenuta dalle considerevoli dimensioni del calcolo e dai ripetuti episodi di infiammazione. Gli Autori descrivono due casi di sindrome di Bouveret accompagnati da una revisione della letteratura medica ponendo particolare attenzione agli aspetti operativi. A causa della rarità di tale entità clinica, i dati reperibili dalla letteratura derivano unicamente dalla pubblicazione di singoli casi, pertanto non esistono trial clinici randomizzati e precise indicazioni terapeutiche. Gli Autori condividono l’opinione per cui la litotrissia endoscopica sia da considerare la scelta più indicata come trattamento di prima linea. Al contrario, l’estrazione endoscopica del calcolo senza frammentazione può essere impiegata solo se le dimensioni del calcolo lo permettono. L’impiego di una litotritore extracorporeo è da valutare solo in casi altamente selezionati in quanto potrebbe aumentare il rischio di complicanze iatrogene, In caso di insuccesso della terapia endoscopica, l’approccio chirurgico è da considerarsi mandatorio.

Dear Editor: Perianal manifestations are quite frequent in Crohn’s disease (CD): simple or complex fistulas, skin tags, haemorrhoids, ulcers, fissures and anal strictures may develop in association with active colorectal inflammation [1, 2]. Symptoms of perianal Crohn’s disease (PCD) vary in terms of severity but are usually recurrent and persistent; combined surgical and medical approach is the gold standard for therapy [1, 2]. Conversely, fistula-associated malignancies are very rare, but few cases among CD patients have been reported in literature; advanced stage at diagnosis and poor outcome are common features [3]. Detection of anorectal carcinoma arising on chronic complex PCD may be challenging, and delayed diagnosis could impair chances of radical treatment. Out of 344 CD-related operations conducted between January 2007 and June 2014 at a single tertiary referral institution, 83 procedures were performed for perianal disease on 60 patients. Four patients were found to have anorectal carcinoma associated with perianal fistula; clinical characteristics, diagnostic and treatment modalities for these patients are presented and discussed. Case 1 A 31-year-old female with a 13-year history of perianal CD and terminal ileitis underwent examination under anaesthesia (EUA) for transsphincteric fistula refractory to treatment. Multiple biopsies demonstrated mucinous anal adenocarcinoma. Abdominoperineal resection extended to the posterior vaginal wall, and coccyx, inguinal linfectomy and ileocecal resection were performed (p T4b N0). She received postoperative chemotherapy and steroids for recurrence of ileal CD. Four years after resection, a pelvic recurrence was detected and chemoradiotherapy started; the patient however died at 53 months from surgery due to disseminate disease. Case 2 A 45-year-old female was admitted for persistent rectovaginal fistula and active colitis. She was diagnosed with perianal CD 23 years before and had previous resection of terminal ileum and right colon. Sphincter-sparing proctocolectomy was performed. On histology, colloid adenocarcinoma of the anus associated with fistula was demonstrated (pT3 N0); she received chemoradiotherapy postoperatively. After 20 months, she developed a pelvic recurrence on the vaginal wall and underwent surgical excision; no signs of further recurrences were seen at 32month follow-up. Case 3 A 44-year-old male was diagnosed with perianal and ileocoecal CD at 21 and underwent ileocecal resection at that time. He was referred to our institution for recurrent abscesses and refractory perianal fistulas; although there was high suspicion for tumour degeneration on first clinical examination, office biopsies failed to demonstrate malignancy. EUAwith deeper biopsies showed mucinous adenocarcinoma of the Electronic supplementary material The online version of this article (doi:10.1007/s00384-015-2140-y) contains supplementary material, which is available to authorized users. A. Zefelippo (*) : S. Costa : E. Contessini-Avesani General and Emergency Surgery Unit, Ospedale Maggiore Policlinico, via F. Sforza 28, 20122 Milan, Italy e-mail: arianna.zefelippo@policlinico.mi.it

A 60-year-old woman with unremarkable medical history, underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis. A four-port technique was performed. Initial exploration of Calot’s triangle was carried out by upward traction of the fundus and lateral retraction of the Hartmann’s pouch; after dissection of the peritoneum medially at the level of the infundibulum, two tubular structures entering the gallbladder were visible, as usually expected. However, to obtain a ‘critical view of safety’,1 dissection was continued by opening up the lateral aspect of the peritoneum; hepatobiliary triangle was dissected free of …

Pyogenic vertebral osteomyelitis is a rare condition usually associated with endocarditis or spinal surgery. However, it may also occur following abdominal penetrating trauma with associated gastrointestinal perforation. Diagnosis might be challenging and appropriate treatment is essential to ensure a positive outcome. In trans-abdominal trauma, 48 hours of broad-spectrum antibiotics is generally recommended for prophylaxis of secondary infections. A case report of vertebral osteomyelitis complicating trans-colonic injury to the retroperitoneum is presented and clinical management is discussed in the light of literature review.