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Arteriovenous malformations of the gastrointestinal tract are a known but rare cause of bleeding. Those of the stomach are the rarest if compared with other causes of gastric bleeding. The aetiology is still unknown, but senile age is considered an important cause, as are the degenerative processes connected with old age. These lesions are diagnosed by endoscopy which, with a haematostatic intent, often is not sufficient to stop the bleeding. Angiography is necessary for patients with massive bleeding whose endoscopy results are negative. The surgical treatment of gastric arteriovenous malformations requires excision of the lesion and part or all of the stomach. We report the case of a 57-year-old patient admitted to the Casualty Department with haematemesis and anaemia caused by acute gastric bleeding.

Splenic abscess is a rare clinical entity; however, thanks to the refinement of diagnostic techniques and to the increase of population at risk its presence is discovered more frequently. In our ward we evaluated a patient by ematochimical and bacteriological exams and abdomen CT. After antibiotical therapy and percutaneous drainage the patient was discharged on the fifteenth day. One month later the patient returned to our emergency room: for the presence of two intrasplenic lesions; he underwent splenectomy. Six month after the operation, the patient was healty. The two methods (surgery and radiological drainage) cannot be compared because the indications are different. Therefore a progressively invasive therapeutic approach would appear to be indicated. If this not successful, splenectomy performed whit laparoscopic or laparotomic techniques should follow.

In the surgical response to gastric carcinoma the use of extensive lymphadenectomy (D2) is still being debated. In Japan D2 is the operation of choice and the numerous selected case studies emphasize better long term survival at all stages with this operation. In the West D2 has not obtained the same approval, besides which it is burdened by higher postoperative morbidity and mortality. The important prospective non-selective trials have not shown differences in the general rates of survival between D1 and D2: the analysis of subgroups, instead, shows better results for stages II and IIIA. The distal splenopancreasectomy and the lack of experience of the surgeons worsen the results of D2. Therefore, when reanalyzing the results of the trials in the light of this information a difference is obtained in the rates of survival in favour of D2 for a wider category of patients. The age of the patient necessitates strict preoperative selection. In some selected cases D2 may be performed; for the majority of older patients the operation of choice is D1 extended to the celiac lymph nodes.

Pancreaticoduodenal resection yields poor results, mainly because of cancer spread into retropancreatic nervous tissue. The aim of this study was to evaluate the feasibility of dissection capable of sparing a portion of retropancreatic nervous tissue in order to lessen, if not prevent, postoperative diarrhoea and severe malabsorption. From April 2000 to June 2001 20 dissections were carried out on 18 fresh cadavers (15 male) within 24 hours of death and on 2 frozen trunks. In all dissections the splanchnic nerves, coeliac plexuses, capital pancreatic plexus and superior mesenteric plexus were identified and traced. The capital pancreatic plexus is composed of two bundles, the first originating in the right coeliac plexus, the second in the superior mesenteric plexus. These two bundles join together just behind the head of the pancreas. The superior mesenteric plexus is composed of two preganglionic bundles, one ganglion, and another two postganglionic bundles. These latter two bundles receive fibres from both the right and left coeliac plexuses. In pancreaticoduodenal resection for cancer, the capital pancreatic plexus has to be completely removed, like the superior mesenteric plexus, as they are very often infiltrated and constitute a route for cancer spread. In small cancers, a thin layer of nervous tissue around the superior mesenteric artery might be spared in order to avoid diarrhoea due to intestinal denervation. The results of this study show that there is anatomical evidence that a thin layer of superior mesenteric plexus receiving fibres from both the left and right coeliac plexuses maintains adequate intestinal innervation.

The modern approach to rectal surgery aims at preserving the nerves to the urogenital system. The relationships between the lateral aspects of the rectum and the surrounding structures represent one of the most controversial points in the surgical anatomy of this area. This study was conducted on 27 fresh cadavers and 5 frozen pelvises. All dissections were performed with a technique similar to that used for the surgical mobilisation of the rectum. The lateral ligaments can be considered extensions of the mesorectum; they originate laterally to the middle portion of the rectum and descend posterolaterally to anchor to the endopelvic fascia. The lateral neurovascular pedicle of the rectum, comprising the middle rectal artery and the transverse autonomic nervous fibres, courses partially beneath the lateral ligament. The urogenital nervous bundle runs close to the point of insertion of the lateral ligaments in the endopelvic fascia, but is not covered with the same layer that forms the ligament itself. Anatomical dissection of cadavers is of invaluable help to the surgeon as it represents the basis for easy recognition of all the various structures in the rectal area.