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Anastomotic stenosis after colorectal surgery is usually considered low-rate complication and often is under-reported in most studies. Few data are available on management strategies. The aim of the study was to assess the prevalence of stenosis after stapled colorectal anastomosis, performed either in elective or emergent setting, for benign or malignant disease, and to evaluate treatment profiles. This retrospective study was a survey conducted in a large Italian North-Eastern area including three regions (Triveneto), over a 12-month period (January–December 2015). Patients’ characteristics and surgical technique details were recorded, along with data on the prevalence of stenosis and its treatment. Patients with mid or low rectal resection and/or neoadjuvant chemo-radio therapy and/or diverting stoma were excluded. The study was promoted by the Italian Association of Hospital Surgeons (ACOI) and the Society of Surgeons of the Triveneto Region. Twenty-eight surgical units were enrolled in the survey, accounting for over 1400 patients studied. Fifty percent of the units performed laparoscopically > 70% of the colorectal resections and 7.5% of the procedures were emergent. Less than 60% of the units planned regular endoscopic follow-up after colorectal resection. Anastomotic stricture was recorded in 2% of the patients; 88% of the stenoses were diagnosed within 6 months from surgery. Only one anastomotic stricture required re-do surgery. The CANSAS study confirms that colorectal anastomotic stenosis is low-rate—but still present—complication. Treatment strategies vary according to surgeons’ and endoscopists’ preferences. Commonly endoscopic dilatation is preferred, but re-do surgery is required in some cases.

Intestinal obstructions/pseudo-obstruction of the small/large bowel are frequent conditions but their management could be challenging. Moreover, a general agreement in this field is currently lacking, thus SICUT Society designed a consensus study aimed to define their optimal workout.The Delphi methodology was used to reach consensus among 47 Italian surgical experts in two study rounds. Consensus was defined as an agreement of 75.0% or greater. Four main topic areas included nosology, diagnosis, management and treatment.A bowel obstruction was defined as an obstacle to the progression of intestinal contents and fluids generally beginning with a sudden onset. The panel identified four major criteria of diagnosis including absence of flatus, presence of3.5 cm ileal levels or6 cm colon dilatation and abdominal distension. Panel also recommended a surgical admission, a multidisciplinary approach, and a gastrografin swallow for patients presenting occlusions. Criteria for immediate surgery included: presence of strangulated hernia, a10 cm cecal dilatation, signs of vascular pedicles obstructions and persistence of metabolic acidosis. Moreover, rules for non-operative management (to be conducted for maximum 72 hours) included a naso-gastric drainage placement and clinical and laboratory controls each 12 hours. Non-operative treatment should be suspended if any suspects of intra-abdominal complications, high level of lactates, leukocytosis (18.000/mm3 or Neutrophils85%) or a doubling of creatinine level comparing admission. Conversely, consensus was not reached regarding the exact timing of CT scan and the appropriateness of colonic stenting.This consensus is in line with current international strategies and guidelines, and it could be a useful tool in the safe basic daily management of these common and peculiar diseases.Delphi study, Intestinal obstruction, Large bowel obstruction, Pseudo-obstruction, Small bowel.Le ostruzioni e pseudo-ostruzioni del piccolo/ grande intestino sono condizioni frequenti, ma la loro gestione risulta spesso difficile per cui è necessario avere un adeguato e condiviso percorso gestionale. A tal proposito la Società Italiana di Chirurgia d’Urgenza e del Trauma (SICUT) ha disegnato uno studio volto a definire il management ottimale dei pazienti con occlusione intestinale.Lo studio è stato condotto utilizzando la metodologia Delphi coinvolgendo un panel di 47 chirurghi italiani con maturata esperienza clinica. Il consenso è stato definito come un accordo uguale o superiore al 75.0%. Lo studio si è focalizzato su quattro aree tematiche comprendenti la nosologia, la diagnosi, la gestione e il trattamento delle ostruzioni e delle pseudo-ostruzioni intestinali. Un occlusione intestinale è stata definita come un ostacolo alla progressione del contenuto intestinale. RISULTATI: in genere ad esordio improvviso. Il panel ha identificato quattro principali criteri di diagnosi, tra i quali l’assenza di canalizzazione ai gas, la presenza di livelli ileali3.5 cm o di una dilatazione del colon6 cm nonché di una distensione addominale. Viene inoltre consigliato il ricovero in chirurgia, un approccio multidisciplinare e un transito con Gastrografin per tutti i pazienti che presentano un’occlusione. Tra i criteri per un intervento chirurgico immediato sono inclusi: la presenza di un’ernia strozzata, una dilatazione del cieco10 cm, segni di ostruzione del peduncolo vascolare e la persistenza di acidosi metabolica. La gestione non operatoria dei pazienti (la cui durata massima dovrebbe essere di 72 ore) include il posizionamento di un sondino nasogastrico e la necessità di effettuare controlli clinici e laboratoristici ogni 12 ore. Il trattamento non operatorio deve essere sospeso in caso insorga il sospetto di complicanze intra-addominali, compaia un alto livello di lattati, una leucocitosi (18.000 / mm3 o neutrofili85%) o un raddoppiamento del livello di creatinina rispetto ai valori basali al ricovero. Al contrario il panel non ha raggiunto alcun consenso riguardo l’esatta tempistica della TAC e l’opportunità di stenting del colon come intervento palliativo in attesa di chirurgia definitiva.Le raccomandazioni stabilite sono in linea con le strategie e le linee guida internazionali, e potrebbero essere uno strumento utile per la gestione del paziente affetto da occlusione intestinale.

Pancreatic cancer (PC) is the fourth cause of cancer death in Western countries, the only chance for long term survival is an R0 surgical resection that is feasible in about 10%-20% of all cases. Five years cumulative survival is less than 5% and rises to 25% for radically resected patients. About 40% has locally advanced in PC either borderline resectable (BRPC) or unresectable locally advanced (LAPC). Since LAPC and BRPC have been recognized as a particular form of PC neoadjuvant therapy (NT) has increasingly became a valid treatment option. The aim of NT is to reach local control of disease but, also, it is recognized to convert about 40% of LAPC patients to R0 resectability, thus providing a significant improvement of prognosis for responding patients. Once R0 resection is achieved, survival is comparable to that of early stage PCs treated by upfront surgery. Thus it is crucial to look for a proper patient selection. Neoadjuvant strategies are multiples and include neoadjuvant chemotherapy (nCT), and the association of nCT with radiotherapy (nCRT) given as either a combination of a radio sensitizing drug as gemcitabine or capecitabine or and concomitant irradiation or as upfront nCT followed by nRT associated to a radio sensitizing drug. This latter seem to be most promising as it may select patients who do not go on disease progression during initial treatment and seem to have a better prognosis. The clinical relevance of nCRT may be enhanced by the application of higher active protocols as FOLFIRINOX.

Patients with ulcerative colitis (UC) and Crohn's disease (CD) are at increased risk of developing intestinal cancers via mechanisms that remain incompletely understood. Several evidences suggest a causal link between chronic inflammation and the development of cancer in the gastrointestinal tract. In fact, patients with UC are exposed to repeated episodes of inflammation that predispose to various tumorigenic events and the sequence of these events are different from those that contribute to develop a sporadic colorectal cancer. In UC carcinogenesis the early events are represented by DNA methylation that produce an inhibition of onco-suppressor genes, mutation of p53, aneuploidy and microsatellite instability. Hypermethylation of tumor suppressors and DNA mismatch repair gene promoter regions, is an epigenetic mechanism of gene silencing that contributes to tumorigenesis and might represent the first step in inflammatory carcinogenesis. P53 is frequently mutated in the early stages of UC-associated cancer, in 33-67% of patients with dysplasia and in 83-95% of UC related cancer patients. Moreover, aneuploidy is an independent risk factor for forthcoming carcinogenesis in UC Finally, the inconsistency between the high cumulative rate of dysplasia in UC and the relatively lower incidence of invasive cancer raises the question about the mechanisms of immunosurveillance that may prevent malignant progression of neoplasm in the colon in most cases. Co-stimulatory molecule CD80 up-regulation in colonic mucosa in UC dysplasia may be one of these mechanism.

The study aim is to confirm feasibility and usefulness of endovascular stent-graft placement for superior mesenteric artery acute bleeding in presence of local sepsis. A superior mesenteric artery resection concomitant to a pancreaticoduodenectomy for carcinoma of the pancreas was followed by a saphenous vein bypass. A pancreatic leak associated to infection developed early in the postoperative course. Three weeks later, a massive haemorrhage due to rupture of an acute pseudoaneurysm was successfully treated with an endoluminal covered stent. This occluded two weeks later without important signs of bowel ischemia. The covered-stent placement allowed obtaining primary hemostasis and bowel perfusion preservation in spite of early occlusion. The patient did well after chemotherapy for one year and presented local recurrence at 16 months. Endovascular treatment of acute haemorrhage in presence of an intra-abdominal sepsis is feasible and useful following pancreatic surgery.

Endoleak (EL) represents the most common complication following endovascular abdominal aortic aneurysm repair (EVAR). Unfortunately, the long-term results of EVAR and its durability have been questioned, and EL are variably associated with a risk of late failure. The aim of this retrospective study was to identify risk factors for this complication of aneurysm-endograft complex in patients who underwent EVAR. A group of 104 consecutive patients (99 men, 5 women; median age, 74 years; range, 50-89 years) were enrolled in the study. Both preoperative and follow-up imaging studies were obtained using helical computed tomography scanning at 1, 6, 12, 24, 36 months after EVAR and blindly reviewed by a surgeon and a radiologist. Twenty-seven (25.9%) patients developed EL during follow-up, of which 10 (37%) were primary (30 days from EVAR), and 17 (63%) were secondary EL. Age and smoking did not affect the EL onset, while a body mass index25 and a history or presence of arterial hypertension represented significant (p0.05) risk factors. Moreover, both greatest diameter and maximum length of the aneurysm were significantly higher (p0.01) in patients who developed EL. No relationship was found with the anatomical features of the aortic neck (i.e. length and diameter), and between the initial size of the aneurysm and the dimension at the time of EL. In conclusion, in our study, being overweight, arterial hypertension and the initial size of the aneurysm represent risk factors for EL development.

Data from 30 consecutive excluded abdominal aortic aneurysms (AAA) have been analysed, to verify whether important morphological changes take place after exclusion, and whether these can be considered as risk factors for functional (leaks, flow alterations) and clinical complications (rupture, obstruction). All AAAs have been initially successfully excluded and patients have been followed up by clinical examinations and ct scan controls post-operatively, at the third and sixth month, then yearly. At a mean follow-up of 17 months, dimension of the proximal neck increased significantly (2 mm in diameter) in five pts and graft was distally dislodged in two. Maximum aneurysm diameter reduced significantly (at east 10% than originally) in half of the case and more than 25% in 10% of cases. Four AAAs presented an initial increase, that reduced only in two. Calculation of length of the AAA was unreliable due to tortuosity. Two secondary type II leaks and one secondary type III leak were observed associated to stable or slightly increased AAA diameter (the latter patient suddenly died probably for miocardial infarction, but a rupture could not be formally excluded). Marked tortuosity of the graft was seen in five patients, all associated with frank shrinkage of the aneurysmal sac. Parietal thrombosis without explanation was observed in five, and in one progressed to obstruction of an iliac branch. Two pts needed anticoagulation. These data indicate that endoluminal aneurysm exclusion can not be considered as a definitive solution, for long-term outcome is unforeseeable in a number of patients.

Background: Iloprost, a prostacyclin analog, reduces hepatic microcirculatory damage after ischemia-reperfusion injury in animal liver models. The objective of this study was to evaluate whether the portal flow velocity changes after Iloprost infusion in patients with systemic sclerosis and Raynaud's phenomenon, who usually have increased risk of microvascular thrombosis and transient liver disturbances. Patients and Methods: Fifteen patients (3 males and 12 females, median age 58 years, range 47-66 years), with systemic sclerosis and Raynaud's phenomenon, were exclusively treated with an infusion of Iloprost (2 ng/kg/min, 6 h/day) for 5 days. In each subject, the portal flow velocity (PV, cm/sec) and portal flow volume (PFV, mL/min) were obtained by using portal color Doppler ultrasonography equipment. Results: Iloprost administration significantly (p