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This study investigated the heme oxygenase-1 (HO-1) and the endotoxin-induced uveitis (EIU) in diabetic streptozotocin (STZ)-hyperglycemic rats. STZ-hyperglycemic rats had impaired levels of the enzyme HO-1 within the ciliary bodies if compared with the nondiabetic rats. STZ-hyperglycemic rats also predisposed the eye to produce high levels of both the cytokines IL-1βand CXCL8. Subsequent EIU further and significantly(P<.01)increased the cytokines production, an effect partly prevented by hemin treatment. Most importantly, hemin, an inducer of heme oxygenase expression and activity, recovered the huge number of infiltrated polymorphonuclear leukocytes PMN within the ciliary bodies associated with STZ-hyperglycemic state and EIU damage. Impairment of the stress-sensitive enzyme HO-1 in STZ-hyperglycemic rats increases and prolongs the inflammatory response to EIU.

Objective: The aim of this study was to evaluate the effects of the selective angiotensin receptor 1 antagonist irbesartan on the growth and differentiation of the adipocytes in obese Zucker fa/fa rats. Research Methods and Procedures: Obese Zucker fa/fa rats were treated by oral route for 3 weeks with irbesartan at doses of 3–10-30 mg/kg per day. The adipocyte differentiation was evaluated by analyzing tissue samples of white (retroperitoneal) or brown (interscapular) adipose tissue for the presence of peroxisome proliferator activated receptor γ, leptin, and the activity of glycerol-3-phosphate dehydrogenase. Results: This study showed that the treatment of obese Zucker fa/fa with irbesartan effectively reduced the differentiation of adipocytes within brown (interscapular) and white (retroperitoneal) adipose tissue. In fact, irbesartan significantly (p < 0.01) and dose-dependently reduced the tissue levels of leptin, peroxisome proliferator activated receptor γ, and the activity of the enzyme glycerol-3-phoshate dehydrogenase accepted markers of adipocyte differentiation. None of the tested doses of irbesartan affected these markers in non-obese rats. Discussion: The antagonism of the angiotensin receptor 1 receptors with irbesartan reduces the adipogenic activity of angiotensin II in obese Zucker rats, with the endpoint being reduction of the growth and differentiation of the adipocytes within the adipose tissue.

A diverticulum of the rectum is a rare complication (2, 5 %) [1, 2] after trans-anal staple procedures, often resulting in faecal matter entrapment leading to the formation of a faecolyth which is likely to obstruct the internal orifice. This can cause local sepsis, eventually requiring reoperation [2]. A 28-year-old female operated on with stapled transanal rectal resection (STARR) for rectocele was referred to our Institution for severe chronic constipation, worsened in the last weeks with fever, abdominal and perineal pain, and rectal bleeding. Clinical examination and MRI revealed a rectal diverticulum with faecal impaction requiring removal under anaesthesia. Five days after stool disimpaction, she underwent MR-defecography which confirmed the presence of one posterior large diverticulum with incomplete elimination of enema. Endoscopy was carefully carried out showing multiple orifices (six) distributed circumferentially along the staple line; two retained agraphes were also identified (Fig. 1a; movie 1). The patient underwent transanal multiple diverticulectomy with direct reconstruction of the rectal wall (Fig. 1b; movie 2). At six months follow-up patient’s symptoms improved and proctoscopy showed good wound healing. The use of trans-anal stapling devices has gained popularity over the last years. Stapled techniques significantly reduce postoperative pain, which is the single most important reason why patients avoid surgery for proctological diseases [3]. However, higher rates of recurrences of symptomatic prolapsing haemorrhoids and obstructed defecation are observed [2, 4]. These may require repeated procedures [4, 5], sometimes technically demanding [5]. In addition, serious complications––unusual with conventional techniques––are reported with trans-anal staplers, also in experienced hands [1]. A iatrogenic rectal diverticulum, seldom observed after STARR [1, 2], may become inflamed with impacted faeces and progress to abscess formation and perforation, condition known as rectal pocket syndrome [1]. We suggest that its prevalence is underestimated because it is often asymptomatic in the short-term, but the effect of a longterm evolution is unknown. Treatment of this condition requires a trans-anal operation that involves experience to face complications that could rise from this relatively simple procedure. We believe that rectal anatomy after STARR is far to be a physiologic rectal anatomy; it produces a weak region (suture line) that is subjected to high pressures, exposing to the risk of complications. Our patient developed a pocket syndrome due to subtle, gradual disruption of the suture line resulting in multiple rectal diverticula formation. When combined with clinical examination, conventional imaging tools are extremely useful in detecting post-operative complications. Dynamic MRI-defecography is non-invasive imaging tool which has several advantages: it offers a clearer visualisation of Electronic supplementary material The online version of this article (doi:10.1007/s13304-014-0274-z) contains supplementary material, which is available to authorized users.

"Background: Double heterozygosity (DH) is an extremely rare event in which both BRCA1 and BRCA2 are mutated simultaneously in a family. To date, few cases of DH have been reported, especially in Ashkenazi populations. In Italy some cases of DH have been reported. In this study, we have described an Italian family with double heterozygosity in the BRCA genes. Methods: The proband is a 43-year-old woman with bilateral breast cancer. She presented two pathogenic mutations in both BRCA genes, IVS8+2T>A (c.547+2T>A;p.Gln148Aspfsx51) in BRCA1, K944X (c.2830A>T;p.Lys944X) in BRCA2 and a novel variant IVS4-57A>G (c.426-57A>G) in BRCA2, not previously described. Both mutations were inherited from the paternal lineage in the proband's family. We investigated all available members of this family and we identified other two family members with DH. Results and conclusions: Our observations support the hypothesis of a non-specific severe phenotype in DH carriers in terms of age of disease onset, cumulative lifetime risk and multiple primary tumours. Furthermore, our findings confirm that in order to identify all cases of DH, it is important not to limit the identification of mutations in a single gene, but extend the analysis to BRCA1 and BRCA2 and other breast cancer susceptibility genes." Background: Double heterozygosity (DH) is an extremely rare event in which both BRCA1 and BRCA2 are mutated simultaneously in a family. To date, few cases of DH have been reported, especially in Ashkenazi populations. In Italy some cases of DH have been reported. In this study, we have described an Italian family with double heterozygosity in the BRCA genes. Methods: The proband is a 43-year-old woman with bilateral breast cancer. She presented two pathogenic mutations in both BRCA genes, IVS8+2T>A (c.547+2T>A;p.Gln148Aspfsx51) in BRCA1, K944X (c.2830A>T;p.Lys944X) in BRCA2 and a novel variant IVS4-57A>G (c.426-57A>G) in BRCA2, not previously described. Both mutations were inherited from the paternal lineage in the proband's family. We investigated all available members of this family and we identified other two family members with DH. Results and conclusions: Our observations support the hypothesis of a non-specific severe phenotype in DH carriers in terms of age of disease onset, cumulative lifetime risk and multiple primary tumours. Furthermore, our findings confirm that in order to identify all cases of DH, it is important not to limit the identification of mutations in a single gene, but extend the analysis to BRCA1 and BRCA2 and other breast cancer susceptibility genes. © 2013 by Walter de Gruyter Berlin Boston 2013.

BackgroundInguinal hernia is the most prevalent among the herniasthat interested the abdominal wall with higher incidencein male than female, moreover it is more frequent inelderly than in younger patients. The incidence risesfrom 11 per 10,000 person-years aged 16-24 years to200 per 10,000 person-years aged 65 years and above.According to the literature the safest approach to geria-tric patients is to perform hernioplasty in open surgeryusing local anaesthesia. The elderly patient has special fea-tures, typically related to thegeneral conditions. Localanesthesia and postoperative analgesia are sufficient tosolve the problems of old age. Over the last twenty yearsthe surgical treatment of inguinal hernias has undergonesignificant changes. Today, the use of prothesis is the tech-nique most used.There are not many differences between the techni-ques “tension free sutures less” and “tension free suturesno less”.MaterialsFrom January 2005 to December 2011 at the Depart-ment of Gerontology, Geriatrics and Metabolic Diseasesat the Second University of Naples, we operated 293patients for inguinal hernia, whose 92 elderly patients(older than 65 years) underwent surgical prosthetic her-nioplasty for simple inguinal hernias. Patients withrecurrence, bilateral hernia, large size hernia and allcases that underwent general anaesthesia were excludedfrom the study.ResultsIn the elderly there are multiple concomitant diseasescompared with young, like respiratory or cardiovascularor metabolic diseases, for example.We reported only 1 recurrence (1.08% of cases) withthe “tensionfreenosutureless” technique. As concernspostsurgical pain, no type of analgesic treatment wasrequired for the most of cases treated.Thanks to the prothesis and concomitant use of localanaesthetic you get a decrease of hospitalization timefor the patients.The duration of surgical treatment is about 45 min;the most of patients were discharged either one dayafter or two days after surgery due to severe concomi-tant pathologies such as ischemic cardiopathy, hyperten-sion, renal insufficiency,obesity, hepatic cirrhosis,moderate-severe BPCO or decompensated diabetesmellitus.The “tension free suture less” and “tension free nosuture less” techniques also decreases morbidity con-nected to respiratory (atelectasis, infection) and circula-tory complications (deep vein thrombosis, pulmonaryembolism). If performed correctly, these techniques,which are based on reinforcing the posterior wall of theinguinal canal through the use of a prosthesis, display arecurrence rate of 0.1-0.3%.The surgical prosthetic hernioplasty associated withthe so-called “nerve sparing” technique - that is to iden-tify and preserve the nerves during surgery - reducepostoperative pain and allow the patients to return soonto them normal physical activity.ConclusionsIt is our opinion that the best treatment of inguinal herniain the elderly patients is the surgical prosthetic hernio-plasty associated with local anaesthesia. It is to be consid-ered, moreover, that thanks to the use of“nerve sparing”

We examined the effects of peri-procedural intensive glycemic control (IGC) during early percutaneous coronary intervention (PCI) on restenosis rate in hyperglycemic patients with ST-segment elevation myocardial infarction (STEMI).A total of 165 hyperglycemic patients (glucose ≥ 140 mg/dl) with first STEMI undergoing PCI were studied. Patients were randomized to IGC for almost 24 h after PCI (n = 82; glucose, 80-140 mg/dl) followed by multidose sc insulin during the hospital stay or conventional glycemic control (CGC; n = 83; glucose, 180-200 mg/dl) followed by conventional therapy. Coronary angiography was performed at study entry and at 6-month follow-up. Blood samples for glycemia, hemoglobin A1c, inflammatory markers (C-reactive protein and TNF-α), monocyte chemoattractant-protein-1, and oxidative stress (nitrotyrosine) were collected immediately before and 24 h, 30 and 180 d after PCI.After insulin infusion, mean plasma glucose during the peri-procedural period was greater in the CGC group than in the IGC group (CGC, 191 ± 15 mg/dl; IGC, 145 ± 35 mg/dl; P0.001). After the insulin infusion period, the levels of markers of oxidative stress (nitrotyrosine), inflammation (C-reactive protein, TNF-α), and monocyte chemoattractant-protein-1 were significantly higher in CGC patients compared with IGC patients. Moreover, ICG during PCI reduces restenosis by half (48 and 24%) at 6 months. During follow-up, there was no difference in mortality rates, glucose, inflammatory and oxidative stress markers among the groups. In-stent restenosis was positively associated with mean plasma glucose levels as well as oxidative stress and inflammatory markers during the insulin infusion period.In hyperglycemic patients with STEMI, optimal peri-procedural glycemic control by reducing oxidative stress and inflammation may improve the outcome after PCI.

Aim The treatment of benign thyroid disease is a topic widely debated, ranging from "Loboistmectomia" to "Total Thyroidectomy". This study aims to contribute to the thinking on treatment strategies for benign thyroid disease. Materials of study 35 patients underwent surgical treatment following the pre-surgical diagnosis of benign thyroid disease between 2003 and 2005 at the Complex Unit of General Surgery and Geriatrics at the Second University of Naples (S.U.N.). In 26 cases total thyroidectomies were performed, in 3 subtotal thyroidectomies, in 6 simple lobectomies. Discussion Post-surgical progress was optimal in the majority of cases. The large number of total thyroidectomies performed is consistent with the trend favoured by this type of strategy. When backed by FNA, non-radical surgery can be opted for with greater confidence for single nodules and when surgical risks are high. The refinement of surgical techniques and directions for the identifying and preparing the recurrent nerve have enabled a radical approach in treating thyroid nodular disease. Conclusions In our opinion, for a solitary nodule with residual diseased parenchyma we believe total thyroidectomy should be prescribed. If, however, the residual parenchyma is unharmed a lobectomy may be considered. For a suspected malignant neoplasia or with widespread disease a total thyroidectomy is necessary. In conclusion, we recommend the individual assessment of each pathology, though we favour total thyroidectomy.

We investigated the Ubiquitin-Proteasome System (UPS), major nonlysosomal intracellular protein degradation system, in the genesis of experimental postsurgical peritoneal adhesions. We assayed the levels of UPS within the adhered tissue along with the development of peritoneal adhesions and used the specific UPS inhibitor bortezomib in order to assess the effect of the UPS blockade on the peritoneal adhesions. We found a number of severe postsurgical peritoneal adhesions at day 5 after surgery increasing until day 10. In the adhered tissue an increased values of ubiquitin and the 20S proteasome subunit, NFkB, IL-6, TNF-αand decreased values of IkB-beta were found. In contrast, bortezomib-treated rats showed a decreased number of peritoneal adhesions, decreased values of ubiquitin and the 20S proteasome, NFkB, IL-6, TNF-α, and increased levels of IkB-beta in the adhered peritoneal tissue. The UPS system, therefore, is primarily involved in the formation of post-surgical peritoneal adhesions in rats.

Background The angiosarcoma of the thyroid gland is a primary malignant highly aggressive tumor. It is classified as a malignant vascular thyroid lesion of mesenchymal origin. In addition to the neck and head, the majority of angiosarcomas also originate from the skin and soft tissues, or limbs of patients with lymphedema. Angiosarcoma of the thyroid is rare and the greatest incidence is witnessed near the Alps. It constitutes only 2-10% of malignant thyroid tumors in Switzerland, Austria and Northern Italy. The prevalence in the Alpine regions can be due probably to iodine deficiency with a long history of endemic goiter. It strikes in old age. There are cases in which the tumor occurs without a history of goiter, and it the occurrence is very unusual in non-alpine areas, so it seemed interesting to present a case involving this type. Due to the increase of the thyroid volume, often occurring in a short time, dyspnea is a frequent symptom, associated with deviation of the tracheal axis. From the macroscopic point of view, this tumor typically appears to be with big dimensions, with large areas of necrosis and hemorrhage. Microscopically, freely anastomosed channels are often associated with a papillary configuration having a pattern of predominant intraluminal growth; the nuclei of the epithelioid endothelial cells are large, vesicular, smooth-contoured, with a large basophilic or amphophylic nucleolus connected by chromatin strands to the nuclear membrane. Typical and atypical mitosis were found in large numbers; the growth pattern is usually highly invasive and tumor necrosis is very strong. Of fundamental importance is the peculiarity that tumor cells express vascular markers such as Factor VIII, CD 31 and CD 34. The distinction between angiosarcoma and anaplastic sarcomatoid carcinoma is difficult and the same expression of the angiosarcoma has been subject to dispute. Clinical history: most of these tumors appear as a poorly encapsulated and infiltrating mass, which tends to grow in the absence of pain. Local recurrence, even after complete excision, and metastasis are common. After diagnosis, patients often die quickly. This type of cancer typically metastasizes in the first instance at the level of regional lymph nodes and lung, in the late stages in the bone marrow. Multimodal treatment, a widely accepted approach, envisages surgery, radiotherapy and chemotherapy. The study was inspired by the observation of a case of thyroid hemangiosarcoma in a 71-year-old man with a history of goiter for twenty years, who decided to undergo an operation for the worsening of the dyspnea.

Background In patients with lower limbs wounds from vasculitis reconstructive surgery with skin grafts can be considered, but this treatment likely fails because of the position, width, and depth of the lesion(s). In these patients a new therapeutic prospect is the use of a dermal matrix that stimulates the production of endogenous collagen before repair with skin graft autografting. Integra® is a semibiological implant consisting of a two-layered membrane that produces a histo-inductive and histo-conductive action on mesenchyme, leading to the formation of normal derma.

This study investigated the role of heme oxygenase (HO)-1 in the cardiac tissue injury of acute ischemia/reperfusion (I/R) in diabetic streptozotocin (STZ)-induced hyperglycemic rats. The effects of 1) hemin, an inducer of HO expression and activity, and 2) zinc protoporphyrin IX (ZnPP-IX), an inhibitor of HO activity, have also been investigated on the tissue injury by I/R and some mediators released in these circumstances. STZ hyperglycemic rats had impaired levels of HO-1 within the cardiac tissue and increased myocardial infarct size (IS) following I/R, as compared with the nondiabetic rats. In these rats, administration of hemin 4 mg/kg 18 h before I/R increases the levels of HO-1 within the tissue. However, the values of HO-1 assayed in these circumstances were significantly lower (P < 0.01) than those assayed in nondiabetic animals subjected to the same procedures; IS was much more extended (P < 0.01) than in the parent nondiabetic group. STZ hyperglycemic rats also predisposed the heart to produce high levels of the cytokines interleukin (IL)-1β and CXCL8. Subsequent I/R further increased (P < 0.01) the cytokine production, an effect partly prevented by hemin treatment. This recovered the huge number of infiltrated polymorphonuclear (PMN) leukocytes within the cardiac tissue associated with the STZ hyperglycemic state and I/R damage.

Aims and backgroundPancreatic resections for neoplastic diseases have a high risk of severe intra- and postoperative complications and are associated with high mortality rates. They should be performed as a rule in centers specializing in this type of surgery. However, it is becoming increasingly likely that such tumors may have to be treated in surgery units which are not specifically dedicated to pancreatic surgery. The aim of this study was to assess the improvements in clinical results in a non-specialized general surgery setting in the light of the most recent progress in surgical techniques, drug treatments and nutritional support.Methods and study designWe analyzed 48 patients with pancreatic cancer treated in our institution over the period from 1980 to 1998: 36 had cancer of the head of the pancreas, 5 of the ampulla, 1 in the second duodenal portion, and 6 of the body-tail. The operations performed consisted of 13 Whipple pancreaticoduodenectomies with cutting and stapling of the distal pancreatic stump at the level of the isthmus, 4 left pancreasectomies, 2 local resections of the ampulla, 21 palliative operations, and 2 exploratory laparotomies.Results and conclusionsThe patients were submitted to follow-up including clinical examinations, blood-chemistry tests, and instrumental investigations. The mean survival was 18 months in the cases where radical surgery was performed, compared to 11 months after palliative surgery. We conclude that an improved prognosis can obtain after pancreatic resection. This is attributable to a more accurate preoperative staging and to the aid of the various forms of nutritional support and pharmacological prophylaxis currently available.

Background. Cancer is one of the most common acquired causes of venous thromboembolism. Aim. To evaluate haemostasis disorders in patients with non-metastatic gastric cancer. Patients and methods. We studied 11 patients with non-metastatic gastric cancer (9 males and 2 females, median age 54 years) and 20 healthy subjects (15 males and 5 females, median age 48 years) control. We measured prothrombin time, activated partial thromboplastin time, coagulation time, clot lysis time, fibrinogen, clotting factors (II, VII, VIII, IX, X), C protein, S protein, AT Ill, activated protein C resistance, prothrombin 1+2 fragment, tissue plasminogen activator, and D-Dimer in all subjects. Results. Fibrinogen plasma levels were significantly higher in patients with non-metastatic gastric cancer than in control group (505±24 mg/dl vs 336±30 mg/dl, p

Peritoneal multicystic mesothelioma is a very rare clinical condition. This neoplastic variant has a high incidence of recurrence after surgical resection. It usually occurs in middle-aged women with a previous history of gynaecological surgery and presents with the symptoms of an abdominal or pelvic mass. The case reported here is that of a 58-year-old woman, characterised first by a left liver-lobe tumour and then by a subsequent episode of emission of cystic matter from an abdominal fistula. The relevant literature is reviewed and the clinical aspects and treatment of this disease are discussed.

The finding of thyroid nodules is a very common occurrence in routine clinical practice. Approximately 5% to 7% of the entire population have thyroid nodules. Vascular lesions are one of the most controversial issues in thyroid pathology. These include benign lesions such as hemangiomas and, rarely, malignant tumors such as angiosarcomas or undifferentiated angiosarcomatoid carcinomas. In particular, angiosarcoma of the thyroid gland is a rare, highly aggressive malignant vascular tumor and in Italy the greatest geographical incidence of this lesion is witnessed near the Alps. Here, a case of thyroid angiosarcoma in a 71-year-old man with a history of goiter for about 20 years is described. The unusual localization of this lesion, the difficulties in reaching a definitive diagnosis for this particular histological type of primary tumor and a history of long-standing multinodular goiter in thyroid of an older man from outside the Alpine region prompted us to report this case of thyroid angiosarcoma mainly to discuss surgical, histopathological and immunohistochemical features.

The results of an experimental study using thymopentin (Timunox) on cancer patients are reported. The drug was administered to 25 patients with cancers of the digestive tract in the form of subcutaneous injections of a vial of the product on alternate days for 36 days. All patients treated revealed a good immune response as indicated by assays of total lymphocytes, T4 lymphocytes the T4/T8 ratio and skin tests, apart from their excellent postoperative recovery. Timunox is therefore considered effective in improving the immune competence of cancer patients.

Aim: The ductal carcinoma in situ is a malignant proliferation of mammary ductal epithelial cells without invasion beyond the basement membrane. The management of patients with DCIS is complex, controversial and has undergone changes over time. Material of study: We treated 65 patients diagnosed with DCIS between 2002 and 2005. We surveyed women aged between 28 and 71 years (average age 51.4), the DCIS in 16 patients appeared as a palpable mass (about 2.2 cm) - group I and in 49 patients as microcalcifications detected on mammography - group II. Results: The most frequent histological type was found to be the comedocarcinoma. After 3 years of follow-up, we had 3 cases of recurrence (4.6%) in patients undergoing conservative surgery, with Van Nuys Prognostic Index between 3 and 4. Discussion: 15-25% of cases of breast cancer are DCIS. Most of these are comedocarcinomas. Comedo form DCIS is an insidious cancer. Surgical treatment ranges from mastectomy to excision of the lesion, often the latter, followed by radiotherapy. Conclusion: We prefer, with regard to surgical treatment, quadrantectomy with systematic control of the free margins. The search for the axillary sentinel node represents for us, too, the gold standard.