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The syndemic framework proposed by the 2021–2030 World Health Organization (WHO) action plan for patient safety and the introduction of enabling technologies in health services involve a more effective interpretation of the data to understand causation. Based on the Systemic Theory, this communication proposes the “Systemic Clinical Risk Management” (SCRM) to improve the Quality of Care and Patient Safety. This is a new Clinical Risk Management model capable of developing the ability to observe and synthesize different elements in ways that lead to in-depth interventions to achieve solutions aligned with the sustainable development of health services. In order to avoid uncontrolled decision-making related to the use of enabling technologies, we devised an internal Learning Algorithm Risk Management (LARM) level based on a Bayesian approach. Moreover, according to the ethics of Job Well Done, the SCRM, instead of giving an opinion on events that have already occurred, proposes a bioethical co-working because it suggests the best way to act from a scientific point of view.

Background Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue tumor that typically affects the lower limbs of men between the ages of 50 and 60. EMC of the shoulder is rare with a high risk of local recurrence and distant metastasis. A planned surgical excision in sarcoma referral centers (SRCs) is mandatory to obtain the best outcome. The role of chemotherapy (CHT) and Radiotherapy (RT) on soft tissue chondrosarcoma is still controversial. Case presentation A 47-year-old man presented to our referral center with a history of EMC in the right shoulder excised with microscopic positive surgical margins in a non-referral center. Staging imaging exams did not reveal distant metastasis or residual disease, but during follow-up a local recurrence was detected. After a multidisciplinary discussion, preoperative radiotherapy was administered with a total dose of 50 Gy, and then the patient underwent wide surgical excision. Histological examination was negative for viable tumor cells. No relapse occurred in a 24-months post-operative follow up. Conclusions The case here described suggests the importance of patient’s management in SRCs. A planned combined treatments with both surgery and RT seems to be the best choice to improve local control. RT seems to be promising within this specific histotype. Further studies are needed to confirm if the observed efficacy of combined treatments reflects in a consistent survival benefit for EMC patients.

BACKGROUND Robotic technologies are being increasingly implemented in healthcare, including urology, holding promises for improving medicine worldwide. However, these new approaches raise ethical concerns for professionals, patients, researchers and institutions that need to be addressed. The aim of this review is to investigate the existing literature related to bioethical issues associated with robotic surgery in urology, in order to identify current challenges and make preliminary suggestions to ensure an ethical implementation of these technologies. METHODS We performed a narrative review of the pertaining literature through a systematic search of two databases (PubMed and Web of Science) in August 2020. RESULTS Our search yielded 76 articles for full-text evaluation and 48 articles were included in the narrative review. Several bioethical issues were identified and can be categorized into five main subjects: 1) robotic surgery accessibility; 2) safety; 3) gender gap; 4) costs and 5) learning curve. 1) Robotic surgery is expensive, and in some health systems may lead to inequality in healthcare access. In more affluent countries the national distribution of several robotic platforms may influence the centralization of robotic surgery, therefore potentially affecting oncological and functional outcomes in low-volume centers. 2) There is a considerable gap between surgical skills and patients' perception of competence, leading to ethical consequences on modern healthcare. Published incidence of adverse events during robotic surgery in large series is between 2% and 15%, which does not significantly differ amongst open or laparoscopic approaches. 3) No data about gap differences in accessibility to robotic platforms were retrieved from our search. 4) Robotic platforms are expensive but a key reason why hospitals are willing to absorb the high upfront costs is patient demand. It is possible to achieve cost-equivalence between open and robotic prostatectomy if the volume of centers is higher than 10 cases per week. 5) A validated, structured curriculum and accreditation has been created for robotic surgery. This allows acquisition and development of basic and complex robotic skills focusing on patient safety and short learning curve. CONCLUSIONS Tech-medicine is rapidly moving forward. Robotic approach to urology seems to be accessible in more affluent countries, safe, economically sustainable, and easy to learn with an appropriate learning curve for both sex. It is mandatory to keep maintaining a critical rational approach with constant control of the available evidence regarding efficacy, efficiency and safety.

Background Myxofibrosarcoma (MFS) is a rare soft tissue sarcoma with a high recurrence rate and a low risk of distant metastasis. It occurs mainly in the extremities of elderly men. Head and neck MFS is extremely rare. Surgery is the cornerstone of treatment. The role of radiotherapy (RT) and chemotherapy (CHT) on MFS is still debated. Case presentation A 67-year-old Caucasian man presented to our sarcoma referral center (SRC) with a history of MFS of the neck excised with microscopic positive surgical margins in a non-referral center. Staging imaging exams did not reveal distant metastasis. After a multidisciplinary discussion, preoperative RT was administered with a total dose of 50 Gy followed by wide surgical excision. Histological examination was negative for viable tumor cells. No relapse occurred during the 24-month postoperative follow-up. Conclusions The case described suggests the importance of planned combined treatments with both RT and surgery for high-grade soft tissue sarcoma. RT seems to be promising within this specific histotype. Close follow-up is advisable in all cases. Further studies are needed to confirm if the observed efficacy of combined treatments results in a prolonged time of disease-free survival and overall survival.

The COVID-19 pandemic induced a global emergency that overwhelmed most hospitals around the world. Access to Hospitals has been restricted to selective oncological and urgent patients to minimize surgeries requiring Intensive Care Unit care. All other kind of non- urgent and benign surgeries have been rescheduled. The burden of oncological and urgent cases on the healthcare system has increased. We have been asked to become the referral center for major oncological and urgent urological surgeries, increasing our surgical volume. Through meticulous hospital protocols on PPE, use of nasopharyngeal swabs, controlled hospital access and the prompt management of suspected/positive cases, we were able to perform 31% more urological surgical procedures during the COVID-19 pandemic compared to the same period in 2019. We observed a 72% increase in oncological surgical procedures and 150% in urgent procedures. Our experience shows how the management of oncological and urgent cases can be maintained during unexpected, global emergencies, such as COVID-19.

In the present study, the protective role of inulin against lipopolysaccharide (LPS)-induced oxidative stress was evaluated on human colonic mucosa using a proteomic approach. Human colonic mucosa and submucosa were sealed between two chambers, with the luminal side facing upwards and overlaid with Krebs (control), LPS or LPS+ inulin IQ solution. The solutions on the submucosal side (undernatants) were collected following 30 min of mucosal exposure. iTRAQ based analysis was used to analyze the total soluble proteomes from human colonic mucosa and submucosa treated with different undernatants. Human colonic muscle strips were exposed to the undernatants to evaluate the response to acetylcholine. Inulin exposure was able to counteract, in human colonic mucosa, the LPS-dependent alteration of some proteins involved in the intestinal contraction (myosin light chain kinase (MLCK), myosin regulatory subunit (MYL)), to reduce the up-regulation of two proteins involved in the radical-mediated oxidative stress (the DNA-apurinic or apyrimidinic site) lyase) APEX1 and the T-complex protein 1 subunit eta (CCT7) and to entail a higher level of some detoxification enzymes (the metallothionein-2 MT2A, the glutathione-S-transferase K GSTk, and two UDP- glucuronosyltransferases UGT2B4, UGT2B17). Inulin exposure was also able to prevent the LPS-dependent intestinal muscle strips contraction impairment and the mucosa glutathione level alterations. Exposure of colonic mucosa to inulin seems to prevent LPS-induced alteration in expression of some key proteins, which promote intestinal motility and inflammation, reducing the radical-mediated oxidative stress.

Summary Background The Universita Campus Bio-Medico (Italy) promotes a summer volunteering work camp (Workcamp Peru) as a social activity for medical and non-medical students. Some junior doctors participate as ‘clinical tutors’, together with tutors from other professions; all clinical tutors have some teaching experience in our teaching hospital. Context The campsite is located in the South of Peru in the Canete Valley, an area characterised by extreme poverty and a severe lack of infrastructure. During the five Workcamp Peru trips that have been organised so far, health science students have carried out many activities for disease prevention and health education, and bio-medical engineering students have organised sessions on the safety of electrical installations, for accident prevention. Innovation and implications We observed that in this setting tutorial activity is fundamental, because it not only offers students an opportunity to learn but also encourages them to react in a more personal and reflective manner to various stressful situations, which often occur in the work camp. The professional competence of the tutor plays an important role before the work camp, in defining the learning objectives for the students and involving them in training sessions held prior to the work camp. Also, during the camp, tutors work with students and also direct the daily briefing and debriefing sessions that are the most important learning activity. For medical tutors involved in the work camp the volunteering experience is a challenge for developing their specific professional and teaching skills, but it also provides an enriching experience in both professional and personal terms. We consider these work camps to be a useful experience in the training of our clinical tutors.

We carried out an audit to verify compliance to Surgical Safety Checklist (SSC), as we have become aware that compliance across different teams and by individual surgeons has not been optimal.100 SSC records from October-December 2014 and 100 from March-June 2015 were inspected to verify correct . 44 surgeons and 34 scrub nurses were asked to complete a questionnaire to know surgeons' compliance to the different stages of the Checklist and the compliance of each surgical team. 100% of scrub nurse and 73.7% of surgeons completed the questionnaire.All Checklist records were correctly filled out but we could verify that while nurses have a strong commitment to the SSC, the Checklist's implementation is not being actively supported by all surgical team members.Many surgeons showed limited awareness of not collaborating during SSC procedure and admitted delegating the responsibility for answering questions to other members of their team. A number of them fell into contradiction answering to various parts of the questionnaire. Consistent with the literature, at our hospital there is a gap between quality of Checklist paper records and correct use of this safety tool.Thanks to the data we have collected we will improve the way the SSC is used and promote change in the behavior of surgeons. Eighteen surgeons (40.9%) expressed willingness to be involved in a work group to revise the SSC and we hope that their commitment to safety and quality will increase.Surgical Safety Checklist, Surgeons commitment.La Checklist per la sicurezza in sala operatoria (Surgical Safety Checklist, SSC) introdotta dall’Organizzazione mondiale per la Sanità (OMS) nel 2008 ed in Italia dal 2009 è in uso da parecchi anni nel Policlinico Universitario Campus Bio-Medico in modo apparentemente in linea con l’atteso ma abbiamo avuto evidenze di un suo utilizzo non corretto, che potrebbe inficiarne l’efficacia come strumento per aumentare la sicurezza. Abbiamo svolto nel 2015 un audit di cui, in questo lavoro, riportiamo alcuni risultati. Sono state esaminate 200 Checklist scelte a caso; sono stati intervistati 44 chirurghi (il 73,7% del totale) e i 34 infermieri del blocco operatorio (100% del personale). Il personale infermieristico è risultato fortemente motivato e attento all’implementazione della SSC. Il “sign-in” ha una elevatissima percentuale di esecuzione. La consapevolezza di alcuni eventi avversi e near miss avvenuti in questa fase ha accentuato la cura con cui sia i chirurghi che gli anestesisti ed il personale infermieristico lo eseguono. Le criticità si verificano nel “time-out” e nel “sign-out”; ci siamo resi conto che – come descritto in letteratura – spesso queste due fasi sono vissute con superficialità e non di rado eseguite senza la reale cooperazione del chirurgo capoequipe e/o dei componenti dell’equipe chirurgica. Questa criticità è stata confermata sia dal personale infermieristico che dai chirurghi; abbiamo potuto verificare che alcuni professionisti non percepiscono il proprio scarso impegno nella procedura di sicurezza della SSC. Da questo audit abbiamo ricavato un piano formativo per il 2016, che coinvolgerà i chirurghi per redigere versioni specialistiche della SSC dell’OMS così da ottenere una maggiore collaborazione ed interesserà tutto il personale per migliorare la rilevazione di eventi avversi legati anche ad anomalie tecniche.

Mesh infection and migration are dangerous and common complications after hernia repair. Many factors cause mesh migration, which may or may not be associated to infection. Before performing hernia repair using a mesh, it is important to choose the right device to avoid this kind of complication, above all in the presence of contaminated wounds or fields. We describe two cases of mesh infection and migration after umbilical hernia repair which were treated, in accordance with recommendations in the literature, by removing the infected mesh and replacing it with a biological mesh. Our experience confirms the feasibility of using biological mesh to perform umbilical hernia repair after infection, with consequent migration, of the previously placed mesh. Our cases are the first to be reported in which mesh migration is associated with infection after umbilical hernia repair, and they demonstrate the advantages of biologic implants in abdominal wall reconstruction.

Background: Promyelocytic leukemia (PML) tumor suppressor gene plays a key role in acute PML pathogenesis but its involvement in pathogenesis and prognosis of solid cancers has not been defined yet. Patients and methods: In all, 62 ampullary adenocarcinoma patients who underwent curative surgery between 1996 and 2005 were included. Expression analysis of PML was carried out by immunohistochemical staining and correlated with disease-free survival (DFS) and overall survival (OS). Results: In 24 tumor specimens (38.7%), PML was classified as absent, in 16 (25.8%) as focally expressed and in 22 (35.5%) as diffusely expressed. By univariate analysis, DFS was significantly influenced by pathological T stage (P = 0.03), lymph nodal involvement (P = 0.002), and PML expression (P = 0.001). DFS in patients without PML expression was 28.0 months versus 45.1 and 75.5 for patients with focal and diffuse expression, respectively. OS in the group of patients without PML expression, with focal expression, and with diffuse expression was 40, 48, and 77 months, respectively (P = 0.002). By a multivariate analysis, PML expression was the strongest prognostic factor for DFS (P = 0.003) and the only statically significant prognostic factor for OS (P = 0.009). Conclusions: Our preliminary data suggest PML as a novel prognostic tool for ampullary cancer patients.

Objective: To examine the mechanisms of action of ursodeoxycholic acid (UDCA) on gallbladder (GB) muscle cells in patients with symptomatic cholesterol gallstones (GSs) as it reduces the incidence of acute cholecystitis. Design and patients: A double-blind study was performed on 15 patients, 7 randomised to UDCA and 8 to placebo, treated for 4 weeks before cholecystectomy. Muscle contraction induced by cholecystokinin (CCK)-8, acetylcholine (ACh) and potassium chloride (KCl) was determined in enzymatically isolated GB muscle cells, and cholesterol levels were determined in plasma membranes. H 2 O 2 , lipid peroxidation, platelet-activating factor (PAF)-like lipids, prostaglandin E 2 (PGE 2 ) and catalase activity were determined as biochemical markers of oxidative stress and inflammation in muscle cells. Results: UDCA significantly increased GB muscle cell contraction induced by all concentrations of CCK-8, ACh and KCl, and reduced the plasma membrane cholesterol (mean (SD) 0.32 (0.16) vs 0.72 (0.5) μmol/mg of protein) compared with placebo. In GB muscle cells, UDCA treatment significantly decreased the levels of H 2 O 2 (4.4 (1.9) vs 13.7 (5.3) μmol/mg of protein), lipid peroxidation (malondialdehyde levels 1.3 (0.4) vs 2.52 (0.7) nmol/100 mg of protein), PAF-like lipids (8.9 (4.9) vs 29.6 (7.1) pg/mg of protein) as well as the production of PGE 2 (142 (47) vs 365 (125) pg/mg of protein) and catalase activity (14.5 (9.4) vs 35.8 (12.7) units/mg of protein) when compared with placebo. Conclusion: These studies suggest that UDCA treatment improves GB muscle contractility by decreasing the cholesterol content in the plasma membrane of muscle cells, and the biochemical parameters of oxidative stress, thus explaining its possible therapeutic mechanisms in patients with symptoms of cholesterol GSs.

Inflammatory myofibroblastic tumor (IMT), also known as inflammatory pseudotumor, plasma cell granuloma or inflammatory myofibroblastoma, is characterized histopathologically by myofibroblastic spindle cells with inflammatory cell infiltrates ( plasma cell, lymphocytes and eosinophils). Inflammatory myofibroblastic tumor is tipically seen in children or young adults and is most commonly localized in the lung, but it can occur anywhere in the body.We present a case in a young woman with severe acute G.I. bleeding, an uncommon presentation of IMT in adults. The patient was admitted to the emergency department for melena. MRI showed a distal jejunum hypervascular mass. Other exams were negative. Surgical excision was recommended, so the patient underwent surgery with complete removal of the tumoral mass. No adjuvant therapy was employed and the patient is asymptomatic after 6 months of follow-up.IMT is an rare lesion that mimics malignancy and is accompanied by various clinical manifestations. The treatment of choice is believed to be complete surgical excision and long term follow up.Anemia, Inflammatory myofibroblastic tumor (IMT), Small intestine, Surgery.È il caso di una paziente di 32 anni affetta da Miofibroblastoma non noto, trasferita da altra struttura sanitaria presso il nostro reparto perché affetta da melena da fonte non determinata. All’anamnesi risultava un precedente ricovero in altro Pronto Soccorso per un quadro clinico caratterizzato da dispnea, cefalea, tachicardia e astenia profonda., oltre a profonda anemia (Hg 5.8 g/dl). La gastroscopia non aveva evidenziato alcun motivo di sanguinamento e l’ecografia addomino-pelvica era risultata negativa. Dopo ripetute emotrasfusioni la tentata rettosigmoidoscopia era stata interrotto per intolleranza della paziente. Una volta stabilizzata si era proceduto al trasferimento presso la nostra struttura, e qui alla Risonanza Magnetica dell’addome veniva evidenziato, un ispessimento parietale esteso per 8 cm a del digiuno medio distale, in corrispondenza del fianco destro, antero – lateralmente al duodeno, ed adiacente ad esso una formazione ipervascolare solida di 20 mm. In prima ipotesi poteva trattarsi di un tratto invaginato del piccolo intestino con all’apice una lesione parietale solida, verosimile causa del sanguinamento. Persistendo il quadro anemico e avendo localizzato una lesione sospetta, la paziente è stata sottoposta ad intervento chirurgico, che portava alla conferma dell’esistenza di una lesione nodulare parietale del piccolo intestino, per cui si procedeva ad una sua resezione segmentaria comprendente la suddetta massa, sottoponendo il pezzo operatorio ad esame istologico definitivo. L’anatomo-patologo formulava la diagnosi isto-immunologica di pseudotumore infiammatorio (c.d. Tumore miofibroblastico infiammatorio) responsabile di invaginazione digiuno-digiunale. I margini di resezione risultavano indenni. Dimessa dopo un decorso postoperatorio senza complicanze, al follow-up di 6 mesi non si è ripresentato alcun sintomo di nuovo sanguinamento. Il sanguinamento della neoformazione responsabile della melena da fonte ignota era dovuto alla ipervascolarizzazione della tumefazione rivelata con la RMN, ed alla soluzione di continuo della mucosa di rivestimento conseguente al trauma della intussuscezione e non semplicemente alla sua struttura istologica. Si conclude per la remota possibilità di un Tumore Miofibroblastico Infiammatorio può essere responsabile di intussuscezione, come ogni massa parietale dell’intestino, e di melena.

The aim of the study was to evaluate the functional results of surgical treatment for intractable slow-transit constipation and to establish that the importance of correct diagnosis and type of colon resection (total or segmental) is essential to achieve optimal outcome while minimizing side effects.Between 1995 and 2004, of the 450 patients presenting with chronic constipation, we further investigated 33 patients with a diagnosis of slow-transit constipation that had not improved with medical or rehabilitative treatment. Preoperative evaluation included a daily evacuation diary compiled using Wexner score, psychologic assessment, Medical Outcomes Study 36-item Short Form Health Survey (SF-36), radiologic investigation of colonic transit time, enema radiograph, colpo-cysto-defecography, anal manometry, and, in selected patients, colonoscopy and pudendal nerve terminal motor latency. In 15 cases, the cause of constipation was colonic slow-transit (with a mean Wexner score of 22), which was always associated with dolichocolon. The other 18 patients presented outlet obstruction, and, therefore, these results are not included in the present report. The 15 patients with slow-transit constipation were submitted to total laparoscopic colectomy (2), total open colectomy (6), and left laparoscopic hemicolectomy for left colonic slow-transit (7).Mean follow-up was 38 months. All patients except 1 presented improvement in symptoms with daily evacuations (P.01; mean Wexner score, 6). Furthermore, results of the SF-36 test showed an improvement in the perception of physical pain, and the emotional, psychologic, and general health spheres after surgical treatment.Meticulous preoperative evaluation of intractable slow-transit constipation may discriminate between the different causes of chronic constipation and thus avoid the well-known "Iceberg syndrome," which is responsible for many treatment failures.

It has been shown, in animal models, that gastrointestinal tract (GIT) motility is influenced by temperature; nevertheless, the basic mechanism governing thermal GIT smooth muscle responses has not been fully investigated. Studies based on physiologically tuned mathematical models have predicted that thermal inhomogeneity may induce an electrochemical destabilization of peristaltic activity. In the present study, the effect of thermal cooling on human colonic muscle strip (HCMS) contractility was studied. HCMSs were obtained from disease-free margins of resected segments for cancer. After removal of the mucosa and serosa layers, strips were mounted in separate chambers. After 30 min, spontaneous contractions developed, which were measured using force displacement transducers. Temperature was changed every hour (37, 34, and 31°C). The effect of cooling was analyzed on mean contractile activity, oscillation amplitude, frequency, and contraction to ACh (10−5M). At 37°C, HCMSs developed a stable phasic contraction (∼0.02 Hz) with a significant ACh-elicited mean contractile response (31% and 22% compared with baseline in the circular and longitudinal axis, respectively). At a lower bath temperature, higher mean contractile amplitude was observed, and it increased in the presence of ACh (78% and 43% higher than the basal tone in the circular and longitudinal axis, respectively, at 31°C). A simplified thermochemomechanical model was tuned on experimental data characterizing the stress state coupling the intracellular Ca2+concentration to tissue temperature. In conclusion, acute thermal cooling affects colonic muscular function. Further studies are needed to establish the exact mechanisms involved to better understand clinical consequences of hypothermia on intestinal contractile activity.

BackgroundFructans, such as inulin, are dietary fibers which stimulate gastro-intestinal (GI) function acting as prebiotics. Lipopolysaccharide (LPS) impairs GI motility, through production of reactive oxygen species. The antioxidant activity of various fructans was tested and the protective effect of inulin on colonic smooth muscle cell (SMC) impairment, induced by exposure of human mucosa to LPS, was assessed in an ex vivo experimental model.MethodsThe antioxidant capacity of fructans was measured in an in vitro system that simulates cooking and digestion processes. Human colonic mucosa and submucosa, obtained from disease-free margins of resected segments for cancer, were sealed between two chambers, with the mucosal side facing upwards with Krebs solution with or without purified LPS from a pathogenic strain of Escherichia coli (O111:B4) and inulin (Frutafit IQ), and the submucosal side facing downwards into Krebs solution. The solutions on the submucosal side were collected following mucosal exposure to Krebs in the absence (N-undernatant) or presence of LPS (LPS-undernatant) or LPS+inulin (LPS+INU-undernatant). Undernatants were tested for their antioxidant activity and the effects on SMCs contractility. Inulin protective effects on mucosa and submucosa layers were assessed measuring the protein oxidation level in the experimental conditions analyzed.ResultsAntioxidant activity of inulin, which was significantly higher compared to simple sugars, remained unaltered despite cooking and digestion processes. Inulin protected the mucosal and submucosal layers against protein oxidation. Following exposure to LPS-undernatant, a significant decrease in maximal acetylcholine (Ach)-induced contraction was observed when compared to the contraction induced in cells incubated with the N-undernatant (4±1% vs 25±5% respectively, PConclusionsInulin protects the human colon mucosa from LPS-induced damage and this effect appears to be related to the protective effect of inulin against LPS-induced oxidative stress.

Impaired gallbladder motility may contribute to gallstone pathogenesis by providing time for nucleation and aggregation of cholesterol crystals. Simultaneous scintigraphic-ultrasonographic techniques have been proposed to assess alternating phases of gallbladder emptying and filling. To evaluate patterns of gallbladder motility and of postprandial bile flow by means of a single ultrasonographic technique, 12 healthy volunteers and 20 gallstone patients underwent minute-by-minute gallbladder ultrasonography for 3 h postprandially. Mathematical analysis of volume measurements was used to estimate hepatic and cholecystic bile flux through the gallbladder. Compared to controls, gallstone patients showed greater amounts of unexchanged cholecystic-to-hepatic bile (11% vs. 1%, p

Background Impairment of gastrointestinal motility is frequently observed in patients with severe infection. Aim To assess whether exposure of human colonic mucosa to pathogenic lipopolysaccharide affects smooth muscle contractility. Methods Human colonic mucosa and submucosa were sealed between two chambers, with the luminal side facing upwards and covered with Krebs solution, with or without lipopolysaccharide from a pathogenic strain of Escherichia coli (O111:B4; 1000 ng/mL), and with the submucosal side facing downwards into Krebs. The solution on the submucosal side was collected following 30-min mucosal exposure to Krebs without (N-undernatant) or with lipopolysaccharide (lipopolysaccharide undernatant). Undernatants were tested for lipopolysaccharide and hydrogen peroxide levels and for their effects on smooth muscle cells in the presence of catalase, indomethacin or MG132. Results Smooth muscle cells incubated with N-undernatant had a maximal contraction of 32 ± 5% that was reduced by 62.9 ± 12% when exposed to lipopolysaccharide undernatant. Inhibition of contraction was reversed by catalase, indomethacin and MG132. Lipopolysaccharide levels were higher in the lipopolysaccharide undernatant (2.7 ± 0.7 ng/mL) than in N-undernatant (0.45 ± 0.06 ng/mL) as well as hydrogen peroxide levels (133.75 ± 15.9 vs 82 ± 7.5 nM respectively). Conclusions Acute exposure of colonic mucosa to pathogenic lipopolysaccharide impairs muscle cell contractility owing to both lipopolysaccharide mucosal translocation and production of free radicals.

Surgical resection at any location in the body leads to stress response with cellular and subcellular change, leading to tissue damage. The intestine is extremely sensitive to surgical stress with consequent postoperative complications. It has been suggested that the increase of reactive oxygen species as subcellular changes plays an important role in this process. This article focuses on the effect of surgical stress on nuclear and mitochondrial DNA from healthy sections of colon and rectum of patients with colorectal cancer. Mitochondrial DNA copy number, mitochondrial common deletion and nuclear and mitochondrial 8-oxo-2′-deoxyguanosine content were measured. Both the colon and rectal tissue were significantly damaged either at the nuclear or mitochondrial level. In particular, mitochondrial DNA was more damaged in rectum than in colon. The present investigation found an association between surgical stress and nuclear and mitochondrial DNA damage, suggesting that surgery may generate an increase in free radicals, which trigger a cascade of molecular changes, including alterations in DNA. © 2011 Indian Academy of Sciences.

Brenner tumors are rare transitional cell tumors of the ovary. They are usually benign neoplasms, of solid or solid-cystic structure and small size. We describe the case of a benign, predominantly cystic Brenner tumor measuring 39 cm in diameter. A 62-year-old woman presented to the outpatient visit complaining about vague abdominal symptoms such as constipation and meteorism. Ultrasonography and CT scan showed the presence of a voluminous cystic mass, with fluid content, displacing other intra-abdominal organs. The patient underwent elective surgical excision, and there were no complications. Definitive pathological examination showed a metaplastic benign Brenner tumor. The largest benign Brenner tumors reported in literature have been up to 30 cm in size, and greater size has been thought to be a predictor of malignancy. We have seen, however, that it is possible for larger lesions of this type to have a completely benign behavior; consequently, a benign nature should not be excluded even in the event of a large ovarian lesion.

We recently reported that, in symptomatic cholesterol gallstone patients, ursodeoxycholic acid (UDCA) improves gallbladder (GB) muscle contractility and decreases the biochemical parameters of oxidative stress and inflammation.1 UDCA also antagonises the hydrophobic bile acid damage to the liver by preventing hydrophobic bile acid-induced stimulation of macrophage oxidative processes.2 3 Macrophages also play a dominant role in the inflammatory and oxidative response in other conditions associated with impairment of intestinal motility, such as post-operative ileus.4–6 Following these findings, we carried out additional studies aimed at examining: the presence of macrophage infiltration and cyclooxygenase-2 (COX-2) expression in the GB muscle layer and the effect of short-term UDCA administration. From February 2004 to August 2007, …

The colon is a rare site of gallstone ileus. We report the case of a woman with cholelithiasis who underwent a total colectomy and cholecystectomy for colon obstruction due to a gallstone impacted in the sigmoid colon narrowed by diverticulitis.

Intestinal tuberculosis is rare in Western countries, with incidence rates of 35.7 and 0.43 per 100,000 per year for the immigrant and native populations, respectively. Despite a clear increase in the frequency of extrapulmonary tuberculosis in immunosuppressed patients, the clinical features of intestinal tuberculosis are seen rarely. A typical clinical presentation includes abdominal pain, weight loss, fever, weakness, nausea, vomiting, obstruction, and bleeding. Intestinal tuberculosis often mimics inflammatory bowel disease or malignant neoplasia, and its preoperative diagnosis is a challenge. Microbiologic diagnosis often is difficult because the causative microorganism requires a long incubation period.Two case reports and review of the pertinent literature.We report two cases of colonic tuberculosis mimicking cecal carcinoma in one patient and periappendiceal abscess in the other. A 75 year-old man underwent right hemicolectomy for a right colon mass. Preoperative laboratory, radiologic, and endoscopic evaluations were negative for tuberculosis and carcinoma. The QuantiFERON-TB Gold test was positive. Surgical specimen histologic review showed non-caseating granulomas and rare Ziehl-Neelsen-positive bacilli. A 35 year-old man, born in Sri Lanka but living in Italy for 10 years, came to our attention for a periappendiceal abscess. Multiple peritoneal micro-nodules were found at laparotomy. Their extemporaneous histologic examination showed granulomas and giant-cell inflammation. A right hemicolectomy was performed. The QuantiFERON-TB Gold test, performed on peritoneal fluid and blood, was positive in both.The QuantiFERON-TB Gold test may hold promise for use in intestinal inflammatory diseases when tuberculosis is suspected but conventional workup is not diagnostic.

Background Gemcitabine is an acceptable alternative to best supportive care in the treatment of advanced biliary tract cancers. The human equilibrative nucleoside transporter 1 (hENT1) is a ubiquitous protein and is the major means by which gemcitabine enters human cells. Moreover, recent reports indicate a significant correlation between immunohistochemical variations of hENT1 in tumor samples and survival after gemcitabine therapy in patients with solid tumors. Materials and methods We used immunohistochemistry to assess the abundance and distribution of hENT1 in tumor samples from radically resected cancer of the ampulla, and sought correlations between immunohistochemical results and clinical parameters including disease outcomes. Results In the 41 individual tumors studied, 12 (29.3%) had uniformly high hENT1 immunostaining. Statistical analysis showed a significant correlation between hENT1 and Ki-67 (P = 0.04). No statistical significant differences were found between immunohistochemical findings and patient characteristics (sex, age, and tumor–node–metastasis). On univariate analysis, hENT1 and Ki-67 expression were associated with overall survival (OS). Specifically, those patients with overexpression of hENT1 showed a shorter OS (P = 0.022) and those with high Ki-67 staining showed a shorter survival (P = 0.05). Conclusions hENT1 expression is a molecular prognostic marker for patients with resected ampullary cancer and holds promise as a predictive factor to assist in chemotherapy decisions.

Capsular splenic metastasis from ovarian cancer, which is associated with peritoneal spread, is not uncommon. Conversely, solitary involvement of the splenic parenchymal is unusual, and secondary debulking may improve the prognosis if there is no sign of residual disease. Thus, splenectomy is indicated for this type of isolated splenic metastasis. We report two cases of successful splenectomy for solitary splenic metastasis of ovarian carcinoma and review the relevant literature.

Chronic intestinal pseudo-obstruction represents a cause of persistent functional intestinal failure either "secondary" to specific conditions or "chronic intestinal idiopathic pseudo-obstruction" in origin. The diagnosis is mainly clinical, supported by radiological and/or endoscopic findings excluding any mechanical cause of intestinal obstruction. We reported a case of a 39-year-old woman with chronic intestinal idiopathic pseudo-obstruction, who underwent colectomy with ileorectal anastomosis; histological examination of the surgical specimen did not reveal myogenic or neurogenic defects or other pathological abnormalities indicative of an underlying neuromuscular impairment. Because of the apparent integrity of the gut neuromuscular layer, we tested whether a functional impairment affected colonic single smooth muscle cells. Muscle cells were isolated from the right colon and their contractile response to a receptor-dependent agonist evaluated in comparison to that obtained from controls. The cell contraction induced by acetylcholine in a dose response manner was markedly decreased in the patient affected by chronic intestinal idiopathic pseudo-obstruction compared with cells from controls (percentage of cell shortening with maximal dose of acetylcholine [10(-6)M]: 10.7+/-3% versus 34.2+/-4%, respectively). The present findings indicate a specific defect of colonic smooth muscle cells likely related to an ineffective response to acetylcholine.

The Postgraduate Surgical education is in an era of transition, in order to create physicians with skills and attitudes needed by modern health care. Many studies have examined the impact of surgical tutoring in surgical residency programs in USA Medical Schools, while few experiences are reported from European Universities. The new Italian guidelines for post-graduate education require a structured clinical learning with the supervision of a tutor ("attending surgeon" for surgical residency); it is a challenge to describe the role of this teacher and educator, and to implement an effective evaluation of operating room teachers. Confidential survey was administered to 14 surgical residents of the Authors' University. Questions were related to their surgical activity and their perception of educational role of tutors in operating room and tutors' teaching behaviors. Residents pointed out five behaviors they perceive as signs of tutor excellence in clinical and operating room setting. According with studies from other Universities, residents need a tutor with competency but also with good teaching skills and a mature self-perception as educator. Faculty would provide training programs for surgeons in order to improve their teaching skills and behaviors.

The Von-Hippel Lindau (VHL) disease is a rare genetically determined syndrome. Clinical course depends on the occurrence of multiple tumors as central nervous system tumors, phaeochromocytoma and renal cell carcinoma. We describe the second case in the literature reporting about a patient affected by a pancreatic neuroendocrine tumor as the first clinical sign of VHL disease. It has been showed that only a strict follow-up can effectively improve survival. Based on the present case, the follow-up of patients affected by VHL syndrome should routinely include functional tests and imaging exams of the pancreas.

Ursodeoxycholic acid (UDCA) prevents in vitro gallbladder (GB) muscle damage caused by acute cholecystitis and reduces risk of biliary pain and complications in gallstone (GS) patients. These effects could be partially explained by the improved GB bile turnover. OBJECTIVES: To assess the effect of short-term UDCA treatment on GB motility and bile turnover. METHODS: Ultrasonographic (US) assessment of GB volumes was performed in 16 GS patients, in the postprandial phase, for 90 min with a time sampling of 1 min, before and after 30 days of UDCA (10 mg kg(-1) die(-1)) or placebo, randomly assigned. US data were analysed with statistical tools and with computer fluido-dynamic (CFD) software Fluent(TM) to simulate GB bile flow. RESULTS: After therapy, fasting volume (FV) increased from 21.6 +/- 9 to 28.2 +/- 12 mL (p < 0.001) while the ejection fraction (EF) remained unchanged (44.5 +/- 17% vs 45.1 +/- 20%; p: ns). Volumes before and after treatment were poorly correlated (0.02 < r < 0.35), unlike those in placebo patients (r > 0.6). The average GB volume was increased in 7 out of 10 patients following UDCA (range 7-67%). CFD analysis supports the finding of improved bile flow after treatment. CONCLUSIONS: Unlike results of conventional US parameters of GB motility, CFD analysis shows that UDCA improves GB bile turnover in GS patients.