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Background The impact of sleeve gastrectomy (SG) on gastroesophageal reflux disease (GERD) is still greatly debated. Most of the current evidence available is solely based on symptom evaluation or medication use, while a minority have implemented objective functional measurements. Objective To better comprehend the pathophysiological mechanisms involved in the genesis of GERD after SG. Setting University Hospital, Italy. Methods A total of 21 patients affected by morbid obesity and eligible for SG were prospectively enrolled in the present study. Patients were evaluated by means of endoscopy, high-resolution manometry (HRM), 24-hour pH monitoring, and the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire. Results Follow-up was completed at least 1 year post operation (mean follow-up, 14.3 ± 2.1 mo) by 19 patients. Body mass index decreased from 41.2 ± .9 to 26.8 ± .8 kg/m2 (P Conclusions Postoperative GERD-related esophageal sequelae should be carefully considered after SG. Our results demonstrate how acid reflux does not seem to play a relevant role in the pathophysiology of post-SG GERD. Baseline HRM can help stratify the risk of developing erosive esophagitis and Z-line upward migration after SG, while postoperative endoscopic surveillance should be encouraged regardless of the presence or absence of symptoms.

Sentinel lymph node (SLN) mapping using near-infrared fluorescence (NIRF) imaging is a recent technique to improve nodal staging in several tumors. The presence of colorectal cancer (CRC) micro-met...

Purpose Aim of this systematic review is to assess the changes in esophageal motility and acid exposure of the esophagus through esophageal manometry and 24-hours pH-monitoring before and after laparoscopic sleeve gastrectomy (LSG). Methods Articles in which all patients included underwent manometry and/or 24-hours pH-metry or both, before and after LSG, were included. The search was carried out in the PubMed, Embase, Cochrane, and Web of Science databases, revealing overall 13,769 articles. Of these, 9702 were eliminated because they have been found more than once between the searches. Of the remaining 4067 articles, further 4030 were excluded after screening the title and abstract because they did not meet the inclusion criteria. Thirty-seven articles were fully analyzed, and of these, 21 further articles were excluded, finally including 16 articles. Results Fourteen and twelve studies reported manometric and pH-metric data from 402 and 547 patients, respectively. At manometry, a decrease of the lower esophageal sphincter resting pressure after surgery was observed in six articles. At 24-hours pH-metry, a worsening of the DeMeester score and/or of the acid exposure time was observed in nine articles and the de novo gastroesophageal reflux disease (GERD) rate that ranged between 17.8 and 69%. A meta-analysis was not performed due to the heterogeneity of data. Conclusions After LSG a worsening of GERD evaluated by instrumental exams was observed such as high prevalence of de novo GERD. However, to understand the clinical impact of LSG and the burden of GERD over time further long-term studies are necessary.

Objective To date, two questionnaires investigating the symptoms of gastroesophageal reflux disease (GERD) (Quality of Life Reflux and Dyspepsia and Reflux Disease Questionnaire) are validated in Italian, but neither of the two questionnaires was correlated with an instrumental examination. The aim of the present study is to improve the GERD-Health Related Quality of Life (HRQL) questionnaire, to evaluate the reliability and validity of its Italian translation, and its sensitivity and specificity. Methods A modified Italian GERD-HRQL (MI-GERD-HRQL) questionnaire was developed adding six questions investigating on regurgitation, for a total of 15 questions. The forward-backward translation process was employed to obtain a definitive from-English-to-Italian version. Data obtained from the questionnaire were compared to upper gastrointestinal endoscopy findings. Results The questionnaire was administered twice to 130 Italian-speaking patients by two different and independent raters. Cronbach's α of the first and second questionnaire was 0.944 and 0.942, respectively. Spearman correlation and inter-rater reliability were 0.923 and 0.929, respectively. Sensitivity and specificity were 73.3 and 64%, and 69.5 and 64%, respectively, for the first and second questionnaire. Conclusion The MI-GERD-HRQL questionnaire proved good consistency, reliability, sensitivity and specificity in the evaluation of typical GERD symptoms.

Background and Objectives: The incidence of diverticulitis is increasing in western countries. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Colonic symptomatic strictures are often treated with segmental colectomy. The aim of our study is to report our experience with Self Expandable Metal Stents (SEMS) placement to relieve sigmoid obstruction secondary to diverticulitis, either as a permanent solution or as a bridge to elective colectomy. Material and Methods: From January 2016 to December 2018, 21 patients underwent SEMS placement for sigmoid obstruction secondary to diverticulitis at our institution. In four patients with poor general conditions, SEMS was considered the definitive form of treatment. In 17 patients, the stent was placed as bridge to elective colectomy. Data were prospectively collected and retrospectively analyzed. Primary outcomes were postoperative mortality and morbidity after SEMS and subsequent elective colectomy. Results: There was no mortality or major morbidity after SEMS placement or subsequent elective colectomy. No stoma was performed. Conclusions: Placement of Colorectal Self Expandable Stent represents a useful tool to relieve obstruction in patients with left-sided colonic diverticulitis. SEMS placement makes it possible to transform an emergency clinical condition into an elective condition, giving time to resolve the inflammation and the infection inevitably associated with complicated diverticulitis.

Purpose: Effects of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms are controversial. Our aim is to evaluate the effects of LSG on GERD symptoms i...

Background and Aims A personalized approach to therapy hold great promise to improve disease outcomes. To this end, the identification of different subsets of patients according to the prevalent pathogenic process might guide the choice of therapeutic strategy. We hypothesize that ulcerative colitis [UC] patients might be stratified according to distinctive cytokine profiles and/or to a specific mucosa-associated microbiota. Methods In a cohort of clinically and endoscopic active UC patients and controls, we used quantitative PCR to analyse the mucosal cytokine mRNA content and 16S rRNA gene sequencing to assess the mucosa-associated microbiota composition. Results We demonstrate, by means of data-driven approach, the existence of a specific UC patient subgroup characterized by elevated IL-13 mRNA tissue content separate from patients with low IL-13 mRNA tissue content. The two subsets differ in clinical–pathological characteristics. High IL-13 mRNA patients are younger at diagnosis and have a higher prevalence of extensive colitis than low IL-13 mRNA patients. They also show more frequent use of steroid/immunosuppressant/anti-tumour necrosis factor α therapy during 1 year of follow-up. The two subgroups show differential enrichment of mucosa-associated microbiota genera with a prevalence of Prevotella in patients with high IL-13 mRNA tissue content and Sutterella and Acidaminococcus in patients with low IL-13 mRNA tissue content. Conclusion Assessment of mucosal IL-13 mRNA might help in the identification of a patient subgroup that might benefit from a therapeutic approach modulating IL-13. Podcast This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast

Patients who had esophagectomy with colon interposition for benign disease have long survivals. Adenocarcinoma arising in the interposed colon is a possible event. We describe a 65-year-old woman in whom we performed 37 years ago an esophagectomy with left colon interposition for lye-induced strictures. At endoscopy an obstructing adenocarcinoma in the interposed colon was detected. She underwent complete endoscopic removal of the tumor. The woman is in good general condition, with a regular diet and without evidence of recurrent disease, 5 years later.

Background and Aims: In ulcerative colitis (UC), inflammation begins in the rectum and can extend proximally throughout the entire colon. The extension of inflammation is an important determinant of disease course, and may be limited by the action of regulatory T cells (Tregs). In this cross-sectional study, we evaluated the relationship between UC extension and the proportions of CD3+CD4+Foxp3+ and CD3+CD4+LAP+Foxp3-Tregs in the colonic lamina propria (LP) of 79 UC patients and 29 controls. The role of these cells in UC extension was also investigated in the murine oxazolone-induced colitis model. Methods: Patients: Disease extension was classified according to the Montreal classification. Where possible, endoscopic biopsies of involved and uninvolved tissue were obtained from UC patients. Mouse model: Colitis was induced by intrarectal oxazolone administration. Lamina propria mononuclear cells were isolated from patient biopsies and mouse colon tissue using enzymatic method and the percentage of CD3+CD4+Foxp3+ and CD3+CD4+LAP+Foxp3-cells evaluated by immunofluorescence. Confocal microscopy was applied for the visualization and quantification of CD4+LAP+ cells on tissue histological sections. Results: In UC patients with distal colitis the proportion of LP CD3+CD4+Foxp3+ Tregs was significantly higher in inflamed tissue than uninvolved tissue. As opposite, the proportion of LP CD3+CD4+LAP+ Tregs was significantly higher in uninvolved tissue than involved tissue. Both LP CD3+CD4+Foxp3+ and LP CD3+CD4+LAP+ Tregs proportion in involved tissue was significantly higher than in controls irrespective of the extension of inflammation. In mice with oxazolone-induced distal colitis, treatment with LAP-depleting antibody was associated with the development of extensive colitis. Conclusions: Our findings suggest that CD3+CD4+LAP+Foxp3-Tregs limit the extension of inflammatory lesions in UC patients.

Background: In Crohn's disease (CD) patients, small intestine contrast ultrasonography (SICUS) accurately assesses small bowel lesions. Its diagnostic role is not known in the assessment of intraabdominal CD complications. The aim was to assess the value of SICUS to detect intestinal complications in patients with CD. Methods: Forty-nine CD patients (21 female, mean age 37.7 years; range 12–78 years) underwent resective bowel surgery and were included in this study. The accuracy of SICUS to preoperatively detect number, site, and length of strictures, fistulas, and abscesses was compared with surgical and pathological findings by kappa statistics. Results: SICUS identified at least one stricture in 39/40 and excluded it in 9/9 (97.5% sensitivity, 100% specificity, k = 0.93); two or more strictures in 9/12 (75% sensitivity, 100% specificity, k = 0.78). The agreement by k-statistics between SICUS and surgery in identifying proximal and distal small intestine site of stricture was 1 and 0.92, respectively. The extension of strictures was 6.8 ± 5.4 cm at surgery, 6.6 ± 5.4 cm at SICUS (NS). Fistulas were correctly identified in 27/28 patients and excluded in 19/21 patients (96% sensitivity, 90.5% specificity, k = 0.88). Intraabdominal abscesses were correctly detected in 10/10 patients and excluded in 37/39 patients (100% sensitivity, 95% specificity, k = 0.89). Conclusions: SICUS is an accurate method for the detection of small intestinal complications in CD. Noninvasive SICUS is valuable as a primary investigative method for evaluating and planning proper treatment in patients with severe CD of the small bowel. (Inflamm Bowel Dis 2011;)

Octyl-2-cyanoacrylate (Dermabond, Ethicon Inc.) has been introduced in clinical practice as an ideal system of closure of wounds, but no studies have confirmed the advantages of wound closure performed with Dermabond compared to skin staples (Proximate, Ethicon Inc.) in thyroid surgery. The objective of this study is to evaluate the short- and long-term results of wound closure in thyroid surgery performed with Dermabond (DERM) versus Proximate (PROX). Seventy patients after thyroidectomy were randomly assigned into the two groups (DERM vs PROX). The postoperative and the long-term outcomes were clinically evaluated by physicians, and the Stony Brook scar evaluation scale has also been used. The patients' satisfaction with the early postoperative management and with the cosmetic outcomes has been assessed by a numerical scale ranging from 0 to 10. Results were compared using appropriate statistical tests. Thirty-two patients used DERM, while 38 patients used PROX. Immediate results showed difficult application in two cases DERM (6.2%) and hyperemia in one case DERM (3.1%). Early results showed edema in eight cases DERM (25%) vs two cases PROX (5.2%; p < 0.05); patients' satisfaction: optimum judgement in 100% DERM vs 15.7% PROX (p < 0.001); patients' self aesthetic evaluation: PROX higher percentage of excellent results vs DERM (p < 0.005). After one month, results showed edema in nine cases DERM (28.8%) vs two cases PROX (5.2%; p < 0.01), while after 6 months, DERM had lesser symptoms than PROX (p < 0.01). Octyl-2-cyanoacrylate has proven to be effective and reliable in the skin closure of cervical incision similar to suture with staples and yields similar final cosmetic outcomes. Because Dermabond offers the advantage of better management in the early postoperative phase, the patients’ satisfaction is clearly better.

International trade of Italian Olive Oil: a perspective analysis - The paper analyses the dynamics of the Italian olive oil trade and gives a preliminary explanation of the opportunity in the international market. The paper starts showing the description of olive oil chain and production and underlining the main factors affecting the import export system. The aim of this work is to explain the magnitude of the trade flows for olive oil from Italy to its main importing countries. This objective has been reached by establishing an appropriate econometric model derived from an extended form of the "Gravity Model". This model has been broadly applied to the analysis of international trade because it provides robust estimates. The results obtained and the model itself are useful in forecasting potential trends in the exportation of high quality Italian olive oil. JEL Codes: Q13, Q17, C20 Key words: Italian Olive Oil, Food-Trade, Gravity Models, Export Analysis

Pouchitis is the most common complication following proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis (UC). To provide a standardized definition of pouchitis clinical, endoscopic and histological markers were grouped and weighted in the pouch disease activity index (PDAI). However, the delay in the assessment of the final score due to the time requested for histological analysis remains the main obstacle to the index implementation in clinical practice so that the use of modified-PDAI (mPDAI) with exclusion of histologic subscore has been proposed. We tested the ability of calprotectin measurement in the pouch endoluminal content to mimic the histologic score as defined in the PDAI, the index that we adopted as gold standard for pouchitis diagnosis. Calprotectin was measured by ELISA in the pouch endoluminal content collected during endoscopy in 40 consecutive patients with J-pouch. In each patient PDAI and mPDAI were calculated and 15% of patients were erroneously classified by mPDAI. ROC analysis of calprotectin values vs. acute histological subscore ≥ 3 identified different calprotectin cut-off values with corresponding sensitivity and specificity allowing the definition and scoring of different range of calprotectin subscores. We incorporated the calprotectin score in the mPDAI obtaining a new score that shows the same specificity as PDAI for diagnosis of pouchitis and higher sensitivity when compared with mPDAI. The use of the proposed new score, once validated in a larger series of patients, might be useful in the early management of patients with symptoms of pouchitis.

Purpose: To prospectively evaluate accuracy of gadobenate dimeglumine–enhanced magnetic resonance (MR) mammography for depiction of synchronous contralateral breast cancer in patients with newly diagnosed unilateral breast cancer or high-risk lesions, with histologic analysis or follow-up as reference. Materials and Methods: The study had ethics committee approval; all patients provided written informed consent. One hundred eighteen consecutive women (mean age, 52 years) with unilateral breast cancer or high-risk lesions and negative findings in the contralateral breast at physical examination, ultrasonography, and conventional mammography underwent gadobenate dimeglumine–enhanced 1.5-T MR mammography. Transverse three-dimensional T1-weighted gradient-echo images were acquired before and at 0, 2, 4, 6, and 8 minutes after gadobenate dimeglumine administration (0.1 mmol per kilogram body weight). Breast Imaging Reporting and Data System (BI-RADS) was used to categorize breast density and the level of suspi...

Background: A CD4+CD25- regulatory T cell population expressing the surface TGF-β in its latent form LAP+ [latency associated peptide] cells was proved to be protective in experimental colitis and to be suppressive of human peripheral blood [PB] T proliferation. We investigated the frequency and function of lamina propria [LP] CD4+LAP+ T cells in inflammatory bowel disease [IBD] patients. Methods: Specimens from patients undergoing colonoscopy or bowel resection for IBD and colonic cancer were used as source of lamina propria mononuclear cells [LPMC]. The ulcerative colitis [UC] group was divided according to endoscopic activity evaluated with modified Baron Score. IL-17, IFN-γ, IL-10, LAP, and Foxp3 expression in CD3+CD8- [CD4] or CD3+/CD4+ gated cell population was assessed by immunofluorescence. The ability of FACS-sorted LP CD3+CD8-[CD4] LAP+CD25- to inhibit stimulated autologous PB CD3+CD8-[CD4] LAP- CD25- cells proliferation was assessed. Results: LP CD4LAP+ cells were significantly increased, when compared with controls, in active UC patients and not in Crohn’s disease patients. The majority of LP CD4+LAP+ cells were Foxp3-. The percentage of IL-17+ cells in LP CD3+CD8-[CD4] LAP+ cells was significantly higher in active UC patients when compared with controls. LP CD3+CD8-[CD4]LAP+CD25- isolated from UC patients showed reduced or no ability to inhibit autologous PB CD3+CD8-[CD4]LAP-CD25- cell proliferation when compared with controls. Removal of IL-17+ cells from LP CD3+CD8-[CD4] LAP+ cells increases their suppressive ability. Conclusions: The percentage of LP CD4LAP+ cells is increased in active UC, showing reduced suppressor activity due to their increased proportion of intracellular IL-17 expression.

Purpose: To establish the value of magnetic resonance imaging (MRI) of the breast in comparison to x-ray mammography and ultrasound for breast cancer evaluation in women with dense breast parenchyma. Materials and Methods: Two hundred thirty-eight women with dense breast parenchyma who were suspicious for breast cancer or inconclusive for the presence of breast lesions based on clinical examination, ultrasound or x-ray mammography, and who underwent breast MRI at 1.5 T before and after administration of 0.1 mmol/kg gadobenate dimeglumine were evaluated. Lesions considered malignant (Breast Imaging Reporting and Data System (BI-RADS) 4 or 5) on x-ray mammography and/or ultrasound and as BI-RADS 3, 4, or 5 on MRI were evaluated histologically. Other lesions were followed up at 6 and/or 18 months. The diagnostic performance (sensitivity, specificity, accuracy, and positive and negative predictive values) of each technique was determined and compared using a general linear mixed model with appropriate correction for multiplicity. Results: At final diagnosis 121 of 238 (50.8%) women had one or more confirmed malignant lesions, whereas 117 (49.2%) had benign lesions or no lesions. Among 97 women who underwent all 3 techniques more lesions (malignant and benign) were detected with breast MRI (n = 135) than with x-ray mammography (n = 85) or ultrasound (n = 107) and diagnostic confidence was greater. In terms of patient-based diagnostic accuracy breast MRI was significantly (P[r] < 0.0001) superior to both x-ray mammography and ultrasound (96.9% accuracy for MRI vs. 60.8% for mammography and 66.0% for US). Malignant lesions were histologically confirmed in 55 of 97 women who underwent all 3 techniques. Breast MRI detected more cases of multifocal, multicentric, and contralateral disease and fewer misdiagnoses occurred. Overall, breast MRI led to a modification of the surgical approach for 28 (23.1%) of the 121 women with diagnosed malignant disease. Conclusion: Breast MRI should be considered for routine breast cancer evaluation in women with dense breast parenchyma.

Background: Probiotics have anti-inflammatory effects in patients with inflammatory bowel disease and appear to regulate mucosal immune response through reductions in proinflammatory cytokines. The probiotic VSL#3 prevents pouchitis if started within a week of ileostomy closure and maintains remission following antibacterial treatment in patients with refractory or recurrent pouchitis. However, the efficacy of probiotics and their effects on regulatory cells if started at a greater time after surgery in patients undergoing ileal pouch anal anastomosis (IPAA) for ulcerative colitis are unknown. Methods: We conducted an open-label study in which 31 patients at different periods from surgery without signs and symptoms of pouchitis were randomized to 2 sachets of VSL#3 once daily or no treatment for 12 months. Pouchitis disease activity index (PDAI) was evaluated at baseline and after 3, 6, and 12 months. The percentage of CD4+ T lymphocytes expressing CD25 and the inactive form of transforming growth factor-β [latency-associated peptide (LAP)] were evaluated at baseline and after 3 and 6 months in peripheral-blood mononuclear cells and mucosal biopsies. Variation in tissue interleukin-1β and Foxp3 mRNA expression was also evaluated. Results: During the study period, VSL#3-treated patients showed a significant reduction in PDAI score and a significant increase in the percentage of mucosal CD4+CD25high and CD4+ LAP-positive cells compared with baseline values. Tissue samples at different points showed a significant reduction in IL-1β mRNA expression, and a significant increase in Foxp3 mRNA expression. Conclusions: We conclude that VSL#3 administration in patients with IPAA modulates the PDAI and expands the number of mucosal regulatory T cells. (Inflamm Bowel Dis 2008)

Background Diagnostic imaging in women with suspected breast cancer should accurately detect and diagnose malignant tumors and facilitate the correct choice of therapy. Contrast-enhanced magnetic resonance mammography (CE-MRM) is potentially the imaging modality of choice for accurate patient management decisions. Methods A total of 164 women with suspected breast cancer based on clinical examination, conventional mammography and/or ultrasound each underwent preoperative bilateral CE-MRM using an axial 3D dynamic T1-weighted gradient-echo sequence and gadobenate dimeglumine as contrast agent. Images were evaluated by two readers in consensus. Histological evaluation of detected lesions was performed on samples from core biopsy or surgery. Determinations were made of the sensitivity, accuracy and positive predictive value of CE-MRM compared to mammography/ultrasound for the detection of malignant lesions and of the impact of CE-MRM for surgical decision-making. Findings Conventional mammography/ultrasound detected 175 lesions in the 164 evaluated patients. CE-MRM revealed 51 additional lesions in 34/164 patients; multifocal and multicentric cancer was detected in 7 and 4 additional patients, respectively, contralateral foci in 21 additional patients and pectoral muscle infiltration in 2 additional patients. CE-MRM also confirmed the absence or benignity of 3 and 1 lesions suspected of malignancy on mammography/ ultrasound. The sensitivity and accuracy for malignant lesion detection and identification was 100% and 93.4%, respectively, for CE-MRM compared to 77.3% and 72.1% for mammography/ultrasound, respectively. Patient management was altered for 32/164 (19.5%) patients as a result of CE-MRM. Interpretation CE-MRM positively impacts patient management decisions and should be performed in all women with suspected breast cancer based on clinical examination, mammography and/or ultrasound.

SUMMARY Transforming growth factor-β (TGF-β) is an inhibitory cytokine recognized as a key regulator of immunological homeostasis and inflammatory responses. TGF-β is involved in experimental models of oral tolerance and in the pathogenesis of experimental colitis. Patients with inflammatory bowel disease (IBD) have inappropriate T cell responses to antigenic components of their own intestinal microflora, suggesting the presence of a disorder in the normal mucosal immune mechanism that ensures the down-regulation of responses to harmless constituents in the microflora. To evaluate the contribution of TGF-β to this imbalance, we measured TGF-β1 production by lamina propria mononuclear cells (LPMC) and T cells isolated from tissue specimens of patients with Crohn's disease (CD), ulcerative colitis (UC) and controls. Cells were cultured in the presence or absence of anti-CD2 plus anti-CD28 MoAbs and TGF-β1 production in culture supernatants was measured by ELISA. LPMC isolated from CD patients produced significantly less TGF-β1 than controls when stimulated via CD2 plus CD28 pathways (P = 0·001)] conversely, in UC patients increased production of TGF-β1 compared to controls was observed (P = 0·0005). These differences were also observed with purified lamina propria (LP) T cells in both diseases and were associated with the presence of inflammation. Thus, TGF-β1 production shows contrasting secretion in CD and in UC, probably as a consequence of the different Th polarization. The absolute or relative defect in TGF-β1 production observed in CD and UC may contribute to the perpetuation of inflammation.

OBJECTIVES: Approximately one third of patients with ulcerative colitis (UC) re - quire surgery. AIM: Aim of this study was to assess the quality of life (QoL) of UC patients who have un - dergone surgery with ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) compared to UC patients not operated. PATIENTS AND METHODS: Fifty consecutive UC patients for each group observed between 1988-2010 were included. To all patients was ad - ministered a self completed questionnaire with four different scores: intestinal symptoms (IS), systemic symptoms (SS), emotional function (EF), social function (SF) and an overall QoL score. RESULTS: Overall QoL score and three dimen - sions (SS, EF, SF) resulted not significantly dif - ferent in the three groups, except for IS that re - sulted worst in the IRA-Group. According to the activity of disease it appeared that UC and IRA patients with mild activity had an overall QoL score similar to patients with complicated IPAA. A higher statistically different score of overall QoL was observed in patients with UC and IRA with moderate/severe disease. CONCLUSIONS: Results of the study demon - strate that overall QoL score is poorer in patients with UC and IRA with mild activity and in patients with complicated IPAA and is worst in patients with UC and IRA with moderate/severe activity .

Dear editor, We read with interest the manuscript recently published by O’Mahoney et al. entitled “Adenocarcinoma of the ileal pouch mucosa: case report and literature review” [1]. The authors well presented a case of adenocarcinoma of ileal pouch mucosa diagnosed after 13 years of pouch creation. They reviewed literature for true pouch adenocarcinoma, and a total of 27 patients have been described around the world. Of these, 63 % (17/27) had neoplasia in their original proctocolectomy specimen. Mean time of adenocarcinoma development was 8.9 years. Five-year survival after excision of the pouch was 70 %. In our experience of 112 ileal pouch anastomosis, we had one case of true pouch adenocarcinoma. A 71-year-old man was diagnosed of ulcerative colitis for 30 years; he underwent a total colectomy 26 years ago (on 1985). Patient course was complicated by chronic pouchitis medically treated. After 11 years of follow-up, primary sclerosing cholangitis diagnosis was done. During annual endoscopic control, a polypectomy was performed. At pathology, a wide area of high-grade dysplasia with a minute focus of adenocarcinoma polyp was observed. A magnetic resonance imaging was performed, and a mucosal thickening was observed. Considering oncological indication to remove the pouch, patient age, and technical difficulty to restore intestinal continuity, the patient underwent ileal pouch excision with end ileostomy. After 34 months of follow-up, the patient is alive with no local or systemic recurrence. In our experience, mean age at surgery was 37 years old with a mean follow-up of 123 months. For a 6-month endoscopical follow-up for the first 4 years after surgery and if no complication is observed, a 12-month control is performed. We agree with O’Mahoney et al. highlighting the need for long-term follow-up and attention to these patients. Through the absence of consensus in the surveillance of pouch, many authors may suggest there own clinical practice [2–4]. However, we suggest to perform a closed follow-up with random biopsy in all patients, with or without previous neoplasia. In patients with ileal pouch anastomosis, no limits of time should be considered to be out of risk.

Background: Restorative proctocolectomy with ileal pouch has become the surgical treatment of choice for patients with ulcerative colitis (UC) and familial polyposis of the colon. Defecography is the radiological technique commonly employed to obtain detailed information on function and morphology of the ileal pouch; it allows the direct visualization of the ileal pouch and the anal canal, but it does not provide the visualization of the pelvis. Methods: In all patients, computed tomography (CT) on coronal planes was performed to determine its possibilities as an alternative to defecography; 10 patients with UC submitted to restorative proctocolectomy and were examined. Results: Coronal CT images provided a panoramic vision of the pelvis and demonstrated the morphology of the ileal pouch, the thickness of its walls, and its correlation with the surrounding tissues. Coronal CT also allowed the evaluation of the continence of ileo-anal and ileo-ileal anastomosis and the functional changes of the perineal muscles at rest and during squeezing. Conclusion: CT images acquired on coronal planes allows an easy and clear detection of the major postoperative complications, such as stenosis or dehiscences of the anastomosis, pelvic phlogosis, and fistulae.

Between 1975 and 1990, 525 patients underwent resection of colorectal cancer in our unit. Of these, 38 had tumour invading adjacent structures and underwent an extended resection. Overall, there were 67 cases treated palliatively. Of these, three were in the group of 38 having an extended resection. When the groups of radical not extended (n = 423) and radical extended resections (n = 35) were compared, respective values for mortality (1.9% vs 0) and morbidity (12.8% vs 11.3%) were not different. Respective local recurrence rates (13% vs 26%) were significantly greater after extended resection. Five-year survival after extended resection was 30%, no different from the general survival rate for standard resections for T2-3 node-positive tumours. Extended resection is thus a safe and important approach for locally advanced tumours.

Highlights • ACC is a rare and aggressive type of tumor, the prognosis is poor. • Frequently, vena cava invasion occurs. • Infrequently, tumor thrombus can extend to the right atrium. • R0 resection is the only curative option. • Thrombectomy required the assistance of cardiopulmonary bypass and hypothermia., Introduction Adrenocortical carcinoma (ACC) is a rare, but highly aggressive type of tumor with an annual incidence of 1–2 cases per million. The prognosis is poor with a five-year overall survival rate of ∼35%. The poor prognosis may be related to the advanced stage at which the majority of ACCs are detected. Complete surgical resection remains the most effective treatment. Presentation of the case A 51-year-old female patient with recent onset of dyspepsia, ascites and peripheral edema was referred to our institution. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) displayed a 8 cm Ø right adrenal mass. Moreover a tumor thrombus jutted out into the IVC, left renal vein and right atrium. An echocardiographic evaluation confirmed the presence of the tumor thrombus in the right atrium. The patient underwent adrenalectomy with removal of its intravascular extension with the assistance of cardiopulmonary bypass and hypothermia. Discussion ACC is a rare malignancy and ACC with tumor thrombus extension is a rare presentation. Patients can present with a variety of sign and symptoms, depending on the extent of the tumor. CT scan of chest and abdomen represents the gold standard in ACC staging while magnetic resonance imaging (MRI) is preferred for tumor thrombus characterization. Complete surgical resection with a negative margin, R0 resection, is the only curative option for localized disease. Kidney sparing surgery should be performed when possible. Conclusion We present a rare case of Adrenocortical carcinoma with tumor thrombus extending into the IVC and right atrium. Complete resection with negative margins represents the best therapeutic chance for these patients.