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Objective Endoscopic ultrasound is the standard procedure for the diagnosis of pancreatic lesions and new needles have been developed to improve tissue acquisition (FNB). Rapid onset evaluation (ROSE) decreases the number of needle passes but is not always available. We introduced an easy and rapid method of direct classification of EUS-FNB sample namely Visual on-site evaluation (VOSE). Aims To assess the accuracy of VOSE in predicting the histological adequacy of specimens. To evaluate the diagnostic power of FNB and the rate of core tissue obtained. Methods Prospective single center study on patients with pancreatic lesions that underwent EUS-FNB. VOSE parameters were presence of blood, macroscopic visible core (MVC), number, color and length of specimen. The association between VOSE tool and histological adequacy was assessed. Fisher’s exact test and Student’s t-test used to compare categorical and continuous variables. Logistic regression analysis was used to assess association between variables. Results 99 patients (58.6% male; mean age 68.4 ± 10) enrolled, including 102 lesions. Total number of passes was 358 with median number of 4 (range, 2–4). The 92.7% of samples were adequate and it was higher with the 22-G needle than with 25G (96.5% vs 89.2% p 0.01). VOSE “red-mixed specimen” was associated with a higher probability of histological adequacy (OR 2.39 95% CI 1.03–5.42 p = 0.04). Conclusions The VOSE tool “red-mixed specimen” can be used to predict the histological adequacy and guide the number of needle passes. Overall, FNB provides a high rate of adequate and diagnostic specimen and high rate of core tissue especially with the 22G needle.

Background While laparoscopic approach for right hemicolectomy (LRH) is considered appropriate for the surgical treatment of both malignant and benign diseases of right colon, there is still debate about how to perform the ileo-colic anastomosis. The ColonDxItalianGroup (CoDIG) was designed as a cohort, observational, prospective, multi-center national study with the aims of evaluating the surgeons’ attitude regarding the intracorporeal (ICA) or extra-corporeal (ECA) anastomotic technique and the related surgical outcomes. Methods One hundred and twenty-five Surgical Units experienced in colorectal and advanced laparoscopic surgery were invited and 85 of them joined the study. Each center was asked not to change its surgical habits. Data about demographic characteristics, surgical technique and postoperative outcomes were collected through the official SICE website database. One thousand two hundred and twenty-five patients were enrolled between March 2018 and September 2018. Results ICA was performed in 70.4% of cases, ECA in 29.6%. Isoperistaltic anastomosis was completed in 85.6%, stapled in 87.9%. Hand-sewn enterotomy closure was adopted in 86%. Postoperative complications were reported in 35.4% for ICA and 50.7% for ECA; no significant difference was found according to patients’ characteristics and technologies used. Median hospital stay was significantly shorter for ICA (7.3 vs. 9 POD). Postoperative pain in patients not prescribed opioids was significantly lower in ICA group. Conclusions In our survey, a side-to-side isoperistaltic stapled ICA with hand-sewn enterotomy closure is the most frequently adopted technique to perform ileo-colic anastomosis after any indications for elective LRH. According to literature, our study confirmed better short-term outcomes for ICA, with reduction of hospital stay and postoperative pain. Trial registration Clinical trial (Identifier: NCT03934151).

Aim: The effectiveness of goal-directed fluid therapy (GDFT) algorithms in improving postoperative outcomes has extensively been suggested. Nevertheless, there is a lack of strong evidence regarding both the clinical impact and the cost–effectiveness of the GDFT protocols. The aim of this study is to evaluate the costs of patients undergoing hepatobiliopancreatic surgery when a GDFT protocol is applied. Materials & methods: Consecutive ASA I–III patients undergoing hepatobiliopancreatic surgery were included in this prospective observational study. Depending on device availability, patients were handled either by fluid therapy guided by Vigileo monitor-derived hemodynamic variables (Vigileo–GDFT group) or by standard fluid treatment (standard group). Postoperative length of stay and economic costs were analyzed. Results: In total, 147 patients were included (71 in the Vigileo–GDFT group and 76 in the standard group). The total hospital length of stay was 13 (median, 1st–3rd quartile, 9–20) days for the Vigileo–GDFT group and 14 (8–21) days for the standard group (p = 0.58); no statistically significant differences between the two groups emerged regarding costs and postoperative complications. In both groups, complications were the main contributor to total cost sustained. Conclusion: The application of a GDFT algorithm did not reduce the total length of hospital stay and the global costs, which were mainly influenced by the number of complications.

BackgroundUse of a locoregional analgesia technique, such as the ultrasound-guided transversus abdominis plane block (TAPb), can improve postoperative pain management. We investigated the role of TAPb in robotic partial nephrectomy, a surgery burdened by severe postoperative pain.MethodsIn this prospective trial, patients with American Society of Anesthesiologists class I–III physical status undergoing robotic partial nephrectomy were randomly assigned to standard general anesthetic plus ultrasound-guided TAPb (TAP group) or sole standard general anesthetic (NO-TAP group). The primary end point was morphine consumption 24 hours after surgery. Secondary outcomes were postoperative nausea and vomiting in the first 24 hours, sensitivity, and acute and chronic pain, as measured by multiple indicators.ResultsA total of 96 patients were evaluated: 48 patients in the TAP group and 48 in the NO-TAP group. Median morphine consumption after 24 hours was higher in the NO-TAP group compared with the TAP group (14.1 ± 4.5 mg vs 10.6 ± 4.6, P ConclusionsOur results show that TAPb can significantly reduce morphine consumption and somatic pain, but not visceral pain. TAPb reduced the incidence of chronic pain.

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

Objective: An intra-aortic balloon pump (IABP) is used routinely in high-risk patients undergoing cardiac surgery to prevent or treat low-cardiac-output syndrome and to reduce perioperative mortality. The insertion and management of IABP carry the risk of major vascular complications. The authors reviewed their database to ascertain the incidence of IABP-related severe complications. Design: A retrospective study. Setting: A teaching hospital. Participants: Ten thousand three hundred sixty-five patients scheduled for elective or emergency cardiac surgery over a 12-year period at a single center. Interventions: Four hundred twenty-three patients received an IABP perioperatively. Careful preoperative screening for peripheral arterial disease, strict postoperative control, and the sheathless insertion technique to spare the arterial flow to the lower limb were performed routinely. Measurements and Main Results: The use of a perioperative IABP was 0.7% at the beginning of the observation period in 1999 and 7.3% in 2010, showing a fluctuating trend. Two patients (0.47%) died of direct complications, arterial wall damage and bleeding. Immediate surgical exploration and control of bleeding were followed by multiple-organ failure and death. Vascular complications, leading to lower-limb ischemia, occurred in 4 of 423 patients (0.94%). All of them underwent urgent vascular surgery and survived. Local sepsis occurred in 2 other patients (0.47%). Conclusions: These data indicate that an IABP is a valuable option in high-risk patients undergoing cardiac surgery even if not devoid of intrinsic risks for vascular complications (0.94%), septic complications (0.47%) and mortality (0.47%). (C) 2012 Elsevier Inc. All rights reserved.

Background/Aims: In partial nephrectomy with hilar clamping every minute of ischemia can impair renal function, thus great importance is having the controlled hypotension as a part of zero ischemia technique. The aim of the study is to evaluate the effects of hypotensive anesthesia on renal function, in patients undergoing robotic assisted partial nephrectomy (RAPN) , during surgery and at 3 months follow up. Methods: This is a prospective study of 100 patients, ASA 1-2, who underwent zero ischemia RAPN under controlled hypotension (CH) from December 2011 through to May 2013. Serum creatinine, BUN, estimated glomerular filtration rates (eGFR), fractional excretion of sodium (FSE) and technetium Tc 99m mercaptoacetyltriglycine (99mTC-MAG-3), renal scintigraphy with effective renal plasma flow (ERPF) were evaluated. Results: Mean duration of CH was 50±4 minutes. Acute renal failure wasn't observed in any of the patients. A significant variation of eGFR during the procedure and 24 hours after surgery was observed. No significant variation of BUN and FSE was detected. Comparing preoperative ERPF of the operated kidney with ERPF 3 months after surgery, it decreased by 2%. Conclusion: In patients with normal preoperative renal function CH didn't show any detrimental impact on renal function during and after robotic assisted partial nephrectomy.

Objective. Continuous surgical wound infusion with local anesthetics is an effective and widely used technique in postoperative pain management. Some aspects of this technique, however, require further investigation. The aim of this study was to retrospectively assess whether continuous infusion of ropivacaine delays the process of wound healing, with an increased incidence of infection. Design. In total, 244 patients aged between 18 and 75 years, American society of anesthesiology II-III, underwent hepatobiliary pancreatic surgery, were classified into two groups and retrospectively analyzed: group R (Ropivacaine) included 152 patients whose surgical incision was fitted with a preperitoneal catheter continuously infusing ropivacaine. Group C (Control) included 92 patients receiving a total intravenous postoperative analgesia. The evaluation forms of the surgical wound according to the Southampton wound assessment scale (SWAS) were collected at three time points. The main outcome was the rate of patients with surgical site infection within 30 days postoperatively. Results. Twenty-one patients (13.8%) in group R and 9 patients (9.8%) in group C ( P = 0.35) presented wound infection. The rate of patients with a wound evaluation of a SWAS grade IV or V in three time frames in Group R and Group C was T0, 1 (0.7%) and 1 (1.08%) ( P = 0.72); T1, 25 (16.4%) and 7 (7.6%) ( P = 0.04); T2, 8 (5.3%) and 5 (5.4%) ( P = 0.53), respectively. Conclusions. The incidence of infection in the surgical site according to the centers for disease control definition was comparable in both groups. The description of the wound healing process according to the SWAS scale shows an initial and temporary decrease in maturation in group R which does not persist in the long-term.

Up to 30% of stage I and II colorectal cancers (CRCs) treated with surgical resection alone show disease recurrence, indicating that lymph node (LN) involvement was probably underestimated. Lung is a common site of CRC metastasis, whereas adrenal glands are rarely involved.On July 2004 a 56-year old woman underwent left hemicolectomy for a stage I sigmoid cancer. Four years later a lobectomy was performed for an isolated lung metastasis; thirteen months thereafter she underwent left adrenalectomy for adrenal metastasis. No lymph node involvement has ever been demonstrated either histopathologically or radiologically. At present, the patient is alive and apparently disease-free.The presence of LN occult metastasis, that might explain recurrence in stage I and II CRCs, has recently been investigated by means of immunohistochemistry and polymerase chain reaction; evidence of LN metastasis obtained with the latter technique is associated to a worse outcome. There have been very few cases that resemble our patient's neoplastic progression and they were either stage III neoplasms or rectal cancers. Our patient's primitive localization in the sigmoid colon makes it difficult to imagine why the liver has not been a site of metastasis. Finally, surgery has an important role in treating isolated metastasis in both lungs and adrenal glands.Colorectal cancer, Lung metastasis, Solitary adrenal metastasis.

INTRODUCTION: Surgical management of left-sided large bowel emergencies has been evolving toward single-staged procedures. Selection for single or staged resection remains the most controversial issue. METHODS: The results from a series of 336 emergency colorectal procedures performed between January 1990 and December 2000 for cancer and diverticular disease by two different surgical units in one hospital are reported: one with a specific interest in colorectal surgery, and one specialized in upper gastrointestinal surgery. RESULTS: A primary anastomosis was performed in 142 (64.3 percent) patients by colorectal surgeons and in 42 (36.5 percent) by noncolorectal surgeons (P < 0.0001). The overall morbidity and mortality rates were lower for colon and rectal surgeons (14.5 vs. 24.3 percent and 10.4 vs. 17.4 percent, respectively). Trainees were more likely to perform anastomoses when assisted by colorectal consultants (72.1 percent of cases) than when a noncolorectal consultant was present (47.5 percent of cases; P < 0.05). The 30-day mortality for patients with primary anastomosis was 6 percent, and anastomotic dehiscence occurred in nine (4.9 percent) patients. The mortality for patients undergoing staged resections (21.1 percent) was significantly higher than those who had primary resections performed (P < 0.001). CONCLUSIONS: Primary anastomosis for left-sided colorectal diseases can be performed with low morbidity and mortality in selected patients. Specialization increased anastomotic rates and reduced morbidity. This study suggests that colon and rectal surgeons should manage colorectal emergencies, and trainees should not be left unsupervised.

The aim of this preliminar report is to evaluate alfa and beta tubulins, components of cellular microtubules, alterated expression in sporadic colorectal cancer patients. The Authors considered 16 patients who underwent surgery for sporadic colorectal carcinoma with radical intent. Alfa and beta tubulins were evaluated in tumoral mucosa by immunohistochemistry. In 56.2% of the examined patients a low expression of alfa and beta tubulins was showed while the alteration of alfa tubulin was showed in 81.2% of the patients. This finding supports the hypothesis of Porter that alterations in microtubule structure might be part of the cellular response to DNA damage.

Objective: Despite emerging evidence suggesting a link between alexithymia and immune function, previous studies yielded contrasting results. The proposed link between alexithymia and immune function remains controversial as does the role, in this relationship, of anxiety, depression and subjective stress. The aim of the study is to investigate the possible association between alexithymia and circulating levels of cytokines in subjects awaiting an upper endoscopy, a stressful procedure, controlling for anxiety levels, depression and subjective stress. Methods: Participants were recruited from among consecutive patients referred for routine diagnostic upper endoscopy. All participants completed the Toronto Alexithymia Scale (TAS-20), the Hospital Anxiety and Depression Scale, and the Stress-related Vulnerability Scale. Serum levels of IL-1β, IL-4, IL-6, IL-10, TNF-α and IFN-γ were measured by ELISA. Results: Of the 90 subjects initially approached, 68 completed the study. The TAS-20 identified 22 alexithymic and 36 non-alexithymic patients. ELISA detected significantly lower IL-4 and IL-6 concentrations in alexithymic than in non-alexithymic patients. According to multiple linear regression analysis, alexithymia predicted low IL-4 and IL-6 levels in the sample overall, independently of stress, anxiety, depression and other possible confounders. No between-group differences were found in serum levels of IFN-γ, IL-1β, and TNF-α. Conclusion: These findings argue against an isolated shift towards pro-inflammatory or anti-inflammatory mediators and suggest that circulating cytokine profiles differ in alexithymic and non-alexithymic subjects.

In this retrospective study, the modality and advantages of the multidisciplinary diagnostic work-up and therapy regarding colorectal neoplasm were analysed. Over the period 2004-2008, 63 patients underwent multidisciplinary treatment for colorectal cancer. All patients underwent surgery (laparoscopic/open). Exeresis was supplemented by adjuvant chemotherapy in those cases beyond IIA stage; all cases of extraperitoneal rectal and anal canal neoplasms plus one case of carcinoma of the transverse colon, initially inoperable, underwent neoadjuvant radiotherapy plus chemotherapy. The treatment was initiated approximately 3 weeks after the diagnosis. Fifty-four percent of patients with colonic and upper rectal neoplasms were given adjuvant chemotherapy, starting around 4 weeks after surgery. Exeresis was performed in those patients with extraperitoneal rectal and anal canal neoplasms (12.7%) about 6-8 weeks after they had completed neoadjuvant therapy. At the end of the treatment, 76% of the overall total numbers of patients were in good condition (follow-up 4-50 months). The remaining 24% suffered recurrences about 13 months after the treatment for colonic and upper rectal neoplasm, and 8 1/2 months after treatment for extraperitoneal rectal/anal canal neoplasms. Seventy-five percent of the recurring cases underwent treatment again, with 50% success; the others are still undergoing treatment. The best therapeutic results were obtained by programmed integration of the various diagnostic-therapeutic steps according to an algorithm which we elaborated to evaluate all types of neoplasm at any stage of illness.

In the industrialized West countries the breast cancer represents the most frequent malignant neoplasia in the women. From over 30 years we have a progressive increase of frequency of breast carcinoma. Mortality is substantially unchanged. The Authors, on the base of casuistry accumulated in five years of activity, trace a diagnostic-therapeutic run to the purpose to favour a line of behavior, practice and actual, for the management of breast cancer.

The Authors report their experience with gastric polyps based upon 3,384 endoscopies performed from October 1992 to August 1995. The incidence of cystic polyps with respect to the examinations performed and to the number of gastric polyps found was 0.45% and 21.3% respectively. The cases were taken into account with respect to sex, age, number of lesions, location, size and association to Gardner's syndrome. A comparison between the observed cases and a comprehensive review of the relevant Literature was performed.

Gastric haemangiomas are an infrequent histological type of gastrointestinal benign tumors. Diagnosis is based on imaging but only pathological examination can give certainty. Endoscopic resection, according some specific criteria, is the gold standard procedure. Authors present a case of cavernous haemangioma diagnosed and treated by endoscopic procedure.

The Authors report the case of a 83 year old woman with large cystic polyps of the stomach. Gastric cystic polyps are polypoid lesions which may develop following functional disorders such as increased mucosal stimulation by gastrin, or excessive retention of gastric secretions. The incidence of these polyps is variable, depending on their being underestimated since they are not always macroscopically visible. The case here reported is very interesting not only for the number of lesions (over 50), but also for their size (5-25 mm in diameter).

Fecal incontinence is commonly caused by structural sphincter damage secondary to obstetric trauma. Anterior sphincter repair achieves reasonable early improvement rates of between 69 and 97 percent. Few series have reported long-term results. This study was designed to evaluate the long-term outcome and examine whether there are any predictive factors that could refine patient selection and predict long-term outcome. The case records of all patients who underwent anterior sphincter repair between January 1991 and December 1999 were studied. The patients were sent a questionnaire that asked about preoperative and postoperative and current bowel function, with questions about quality of life and overall satisfaction with the outcome of the procedure. The late outcome after a mean period of 70 months from the operation was compared with the early clinical results. All the preoperative and operative variables were studied to ascertain their significance in predicting success. Ninety-three patients were admitted to the study. Anterior sphincter repair was successful in improving continence in 73 percent of patients. Long-term results were obtained for 62 patients. Seventy percent had objective clinical improvement based on the questionnaire, but only 55 percent considered their bowel control had improved and only 45 percent were satisfied by the operation. Urgency was the most important symptom in determining patient satisfaction; 24 of 26 patients in whom urgency had improved were happy with their outcome. None of the preoperative and operative variables predicted the outcome. Patients should be warned that complete continence is difficult to achieve and that symptoms tend to deteriorate with time.

On a study population of 131 patients the Authors evaluate possible differences related to the use of H2 blockers. Patients were divided in 2 groups: one (70 cases) studied before the introduction of H2 blockers and the other (61 cases) treated with H2 blockers. The influence of endoscopy for the early diagnosis of gastric cancer was also considered. The Authors conclude that H2 blockers do not have a negative influence from a surgical point of view, however the correct diagnosis may often be delayed and this is not acceptable for an era in which early diagnosis is feasible.

The authors report a case of HIV-1 infection, primary miliary tuberculosis of the lung and secondary intestinal tuberculosis complicated with multiple intestinal perforations. The surgical emergency therapy, supported by specific antitubercular drugs, antibiotics, and total parenteral nutrition, consisted in suturing seven perforative sites of the small and large intestine. The Authors stress the possibility that in the future tubercular complications up till now considered atypical may become more and more frequent because of the HIV-1 infection association.

Background The surgical management of left-sided large bowel emergency patients remains controversial. There has been an increasing trend towards primary reconstructive surgery. The main dilemma remains appropriate patient selection for primary anastomosis. Methods The records of 323 patients who presented as acute emergencies and underwent surgery between January 1990 and December 2000 for left-sided colorectal cancer and diverticular disease were reviewed, to compare the outcome of resection and primary anastomosis with Hartmann's procedure. Patients were stratified into 3 groups according to whether the presentation was with localized or generalized peritonitis, or with obstruction. Results Resection and anastomosis was carried out in 176 (55.7%) patients with a 30-day mortality of 5.7%. Anastomotic dehiscence occurred in 9 (5.1%) patients, with no difference between the three groups. Wound sepsis occurred in 8 (4.5%) patients, and the median hospital stay was 13 days. Hartmann's resection was associated with a higher incidence of systemic and surgical morbidity (39.5% and 24.3%, respectively). The mortality rates in those selected for primary anastomosis (5.7%) compared favourably with those undergoing Hartmann's resections (20.4%) (P

The surgical treatment of large bowel malignant tumors is now the most important therapeutic approach. The aim of our study was to evaluate a possible prognostic implication of ploidy and NM23 expression. The study includes 120 non selected patients who underwent surgery for colorectal cancer. The analysis of ploidy was obtained with cytometric test. The cases with only one gaff G0/G1 were considered as diploid. Patteras with more than one aneuploidic population were classified as multiploidic or poliploidic. While NM23 expression was evaluated with a double blind retrospective study by two separate equipe of authors in different centres. NM23 positivity degree was classified in 3 classes: absent or weak if10%; moderate if 10-50%; strong if50%. Forty-two patients (35%) were classified as diploidic; 30 patients (25%) as aneuploidic; 40 patients (33.2%) as multiploidic; in 8 cases (6.7%) the material was inadequate. Among the two groups who evaluated NM23 expression the group I a positivity: absent or weak in 32 cases (26.7%); moderate in 62 cases (51.7%); strong in 26 cases (21.6%); while the group II shows positivity: absent or weak in 30 cases (25%); moderate in 52 cases (43.3%); strong in 38 cases (31.7%). We cannot consider ploidy and the NM23 research as independent prognostic factor.

Studies regarding the associations between different types of cancer in the same patient are very few and not always come to the same conclusions. Several hypothesis are suggested and particularly genetic and socioeconomical ones seem to offer an interpretation of this issue. Early detection of a second neoplasm allows to improve prognosis and survival. The knowledge of correlations between tumors help to select a population, with a high risk to develop a second cancer, to be included in a screening program. Nowadays thanks to early detection of breast cancer, ten years survival is more than 75%. Women who had breast cancer now live longer and so could have a higher risk to develop a second cancer.From September 1998 to September 1999 in our Department 71 patients operated for breast cancer, underwent screening colonscopy. No patients refused to be included in the study. Mean age was 61 years (range 36-87). Each patient had a clinician interview in order to explain the goals of the study.Results show that among all patients 3 (4.2%) presented a history of colon cancer, 18.3% (13 cases) presented large bowel polyps. In 84.60% patients (11 cases) polyps were found not over 40 cm. This study shows that 93% of patients (66 cases) had a relative with cancer history.Our results compared with those of other authors seem to show an increased risk for breast cancer patients in developing polyps or colon cancer, so we suggest to insert sigmoidoscopy in standard follow-up of breast cancer patients.

To understand the level of acceptance, awareness and usefulness of informed consent, a group of 119 patients (59 men and 60 women) from different types of hospitals were given a questionnaire which required only 'YES or NO' answers, both before and after surgery. The questionnaire concerned the patient's knowledge about pathology, operative risks, approval, anxiety caused, understanding of information received and consent given, and also if he would inform a relative in the same condition. From the analysis of the results it was established that: the more information a patient has about his illness and operation risks, the more he will want to have; the less he knows the less he will want to know, and he will also have more faith in the doctors. Some patients would not inform a relative with a similar pathology. To conclude, informed consent, instead of being a right of the patient is progressively becoming more a right of the doctor. It does not have any real effect on the patient's choice but is useful, as it represents a moment of personalised attention from medical personnel, though the patient may not completely understand the information received. There are few advantages in strictly medical terms but informed consent has increased malpractice litigation.

Intranuclear DNA imaging may be considered as a marker of the biological behaviour of neoplasias. However, some questions fundamentally related to the interpretation of cytometric data, to the correlation with other histomorphological parameters and to tissue sampling concerning staging and prognostic evaluation of colon cancer patients are still unsolved. A way to solve this problem may be to perform multiple full thickness samplings.

The authors report the case of a 39-year old woman who had a fast and dramatic weight loss after an intestinal bypass performed elsewhere. The result was a generalized skin flakiness which caused dissatisfaction and psychological unbalance of the patient. Three plastic surgeries were therefore programmed and performed at different moments: mastopexy, abdominoplasty and upper thigh dermolipectomy. No immediate or late complications were observed, even after 2 years. The authors stress the importance of a correct planning of a plastic surgery as a solution to the generalized tissue flakiness in the formerly obese patient.

Interest about hemorrhoids is related to its high incidence and elevated social costs that derive from its treatment. Several comparative studies are reported in Literature to define a standard for ideal treatment of hemorrhoidal disease. Radical surgery is the only therapeutic option in case of III and IV stage haemorrhoids. Hemorrhoids surgical techniques are classified as Open, Closed and Stapled ones.We report our decennial experience on surgical treatment focusing on early, middle and late complications, indications and contraindications, satisfaction level of each surgical procedure for hemorrhoids.Four hundred forty-eight patients have been hospitalized in our department fom 1st January to 31st December 2008. Of these 241 underwent surgery with traditional open or closed technique and 207 with the SH technique according to Longo. This retrospective study includes only patients with symptomatic hemorrhoids at III or IV stage.There were no differences between CH and SH about both pre and post surgery hospitalization and intraoperative length. Pain is the most frequently observed early complication with a statistically significant difference in favour of SH. We obtain good results in CH group using anoderma sparing and perianal anaesthetic infiltration at the end of the surgery. In all cases, pain relief was obtained only with standard analgesic drugs (NSAIDs). We also observed that pain level influences the outcome after surgical treatment. No chronic pain cases were observed in both groups. Bleeding is another relevant early complication in particular after SH: we reported 2 cases of immediate surgical reintenvention and 2 cases treated with blood transfusion. Only in SH group we report also 5 cases of thrombosis of external haemorrhoids and 7 perianal hematoma both solved with medical therapy There were no statistical significant differences between two groups about fever, incontinence to flatus, urinary retention, fecal incontinence, substenosis and anal burning. No cases of anal stenosis were observed. About late complications, most frequently observed were rectal prolapse and hemorrhoidal recurrence, especially after SH.Our experience confirms the validity of both CH and SH. Failure may be related to wrong surgical indication or technical execution. Certainly CH procedure is more invasive and slightly more painfull in immediate postoperative period than SH surgery, which is slightly more expensive and has more complications. In our opinion the high risk of possible early and immediate complications after surgery requires at least a 24 hours hospitalization length. SH is the gold standard for III grade haemorrhoids with mucous prolapse while CH is suggested in IV grade cases. Hemorrhoidal arterial ligation operation (HALO) technique in III and IV degree needs further validations.

Patients affected by hilar cholangiocarcinoma are eligible for surgery only in the 20-30% of the cases and postoperative mortality is 40-50%. Many specialists are involved in the treatment of this disease, like surgeons, gastroenterologists, oncologists and radiotherapists. Recent studies have shown that preoperative bilirubinaemia is a predictor of morbidity and mortality after surgery. Coupled Plasma Filtration and Adsorption (CPFA) is a blood purification extracorporeal therapy recommended for sepsis and able to reduce bilirubinaemia.We treated 10 patients referred to our centre affected by hilar cholangiocarcinoma complicated by obstructive jaundice with 34 CPFA sessions to test its ability to reduce preoperative bilirubin levels and we checked for mortality at 90 days.CPFA reduced preoperative bilirubin of 30% for session; it also improved others inflammation and coagulation tests. Mortality at 90 days was 40%.CPFA is an effective therapy for hyperbilirubinaemia. Lowering preoperative bilirubinaemia and improvement of coagulation tests subsidized the management of the patients but in our study did not affect postoperative mortality. Further studies to evaluate the indications for treatments that remove bilirubin in this setting are needed.

We report our clinical experience with incisional hernia surgery and we retrospectively analyze the outcomes obtained with the different techniques of repair used, confirming that Rives-Stoppa procedures actually represent the gold standard for incisional hernia.334 patients were observed for incisional hernioplasty at our Department of Surgery from 1996 to 2007. They were treated according to the following surgical procedures: 44 primary direct closures; 246 Rives-Stoppa procedures; 9 Chevrel procedures; 35 intraperitoneal repairs. The outcomes were considered in terms of postoperative surgical complications.In total, we had 13 cases of hernia recurrence (3.9%), 14 cases of infections (4.2%), 7 cases ofseroma/hematoma (2.9%) and one case of acute respiratory insufficiency.The choice of the surgical technique depends on several factors, such as the size of the hernia defect and the representation of the anatomical structures, essential for the reconstruction of the abdominal wall. We abandoned Chevrel technique due to high rate of recurrence and infective complications and reserved the intra-peritoneal repair only for cases where a fascial layer could not be reconstructed. Instead, the primary direct closure should be considered for high risk patients because of its low surgical impact, although it is characterized by higher incidence of recurrence. Combining the Rives-Stoppa technique with some personal technical modifications, we obtained acceptable results in terms of recurrence rate and morbidity.Rives-Stoppa procedures are the current standard of care for the surgical repair of incisional hernia and our treatment of choice.

Background Recurrence and severity of Crohn's disease mucosal lesions after "curative" ileal resection is assessed at endoscopy. Intramural lesions can be detected as increased wall thickness at Small Intestine Contrast Ultrasonography (SICUS). Aims. To assess after ileal resection whether: 1) SICUS detects recurrence of Crohn's disease lesions, 2) the intestinal wall thickness measured at the level of ileo-colonic anastomosis predicts the severity of endoscopic lesions, 3) the extension of intramural lesions of the neo-terminal ileum is useful for grading severity of the recurrence, 4) the combined measures of wall thickness of the ileo-colonic anastomosis and of the extension of intramural lesions at level of the neo-terminal ileum may predict the endoscopic Rutgeerts score Methods Fifty eight Crohn's disease patients (M 37, age range 19-75 yrs) were prospectively submitted at 6-12 months intervals after surgery to endoscopy and SICUS for a total of 111 observations. Results Six months or more after surgery wall thickness of ileo-colonic anastomosis > 3.5 mm identified 100% of patients with endoscopic lesions (p < 0.0001). ROC curve analysis, combining wall thickness of ileo-colonic anastomosis and the extension of intramural lesions of neo-terminal ileum, discriminated (0.95) patients with, from those without, endoscopic lesions. Performing two multiple logistic regression analyses only wall thickness of ileo-colonic anastomosis and extension of neo-terminal ileum intramural lesions were significantly associated with absence or presence of endoscopic lesions. An ordinal polychotomus logistic model, considering all investigated variables, confirmed that only SICUS variables were associated with endoscopic grading of severity. Conclusions In patients submitted to ileal resection for Crohn's disease non-invasive Small Intestine Contrast Ultrasonography 1) by assessing thickness of ileo-colonic anastomosis accurately detects initial, minimal Crohn's disease recurrence, and 2) by assessing both thickness of ileo-colonic anastomosis and extension of intramural lesions of neo-terminal ileum grades the severity of the post-surgical recurrence.