Open sphincter-preserving surgery of extraperitoneal rectal cancer without primary stoma and Fast Track Protocol.

AIM: Fast track protocol (FTP) showed to improve perioperative care. The study aims to evaluate the impact of the FTP in the open extraperitoneal rectal cancer (ERC) surgical treatment without a primary derivative stoma (DS) and the QoL in patients with or without a secondary DS. PATIENTS AND METHODS: 50 patients affected by ERC were enrolled and operated on with open low anterior resection without a primary DS. They were randomized in two groups: one was treated perioperativelly in the traditional way (group T), the other using a modif ed FTP (group FT). A QoL questionnaire was administered prior to discharge and at 1-month follow-up. RESULTS: Five courses (10%) were complicated by anastomotic leakage: 3 (12%) in the FT group (2 minor and 1 maior) and 2 (8%) in the T group (1 minor and 1 maior) (p=n.s.). All the maiors and one minor were treated with a DS. Patients of the group FTP were considered dischargeable earlier that those of group T (p<0.05). Patients with DS had a significantly lower QoL score (p<0.0001). CONCLUSION: FTP with minor modifications is feasible and safe in the ERC open surgery without using a DS. Better results were obtained without increasing complication rate. A secondary DS impacts detrimentally on QoL.

A comparison of the outcome using Ligasure™ small jaw and clamp-and-tie technique in thyroidectomy: a randomized single center study.

PURPOSE: Hypoparathyroidism and paralysis of the recurrent laryngeal nerve (RLN) still remain the most frequent specific complications of thyroid surgery. This study evaluates the effects of employment of a recently introduced device (LigaSure™ Small Jaw, LSJ), compared to the traditional clamp-and-tie (CT) technique, on the short- and long-term outcome of the patients who underwent thyroidectomy. METHODS: This prospective, randomized study included 190 patients enrolled from October 2011 to July 2013. The numbers of patients in the LSJ group and the CT group were both 95. We studied the following: operative times, intraoperative and postoperative blood losses, intact parathormone (iPTH) and calcium serum levels, and the incidence of RLN paralysis. RESULTS: The two cohorts were homogeneous for age, sex, surgical indication, BMI, ASA score, and estimated thyroid volume. Operation time has been 73.90 ± 23.35 min in group CT and 60.20 ± 22.36 min in group LSJ (p = 0.002). Intraoperative blood losses have been 47 ± 18 ml in group CT and 38 ± 14 in group LSJ (p = 0.002), while postoperative blood losses have been 45 ± 21 ml in group CT and 40 ± 20 in group LSJ (p = 0.105). The mean calcium blood level in group CT has been 8.12, 7.79, and 7.92 mg/dl in the first, second, and third postoperative days, respectively, as well as 8.26, 7.97, and 8.22 mg/dl for group LSJ (p > 0.05). Basal and post-thyroidectomy iPTH levels have been 46.49 and 23.64 pg/ml in group CT (Δ = 49.15 %), as well as 51.06 and 27.73 (Δ = 45.69 %) in group LSJ (p > 0.05). Permanent RLN paralysis was 1.05 % in LSJ group and 0 % in CT group. CONCLUSION: The employment of LSJ reduces in a statistically significant way both operative times and intraoperative blood losses. No significant differences were found as far as postoperative RLN paralysis and hypoparathyroidism.

Sustainability evaluation of Sicily's lemon and orange production: an energy, economic and environmental analysis.

The island of Sicily has a long standing tradition in citrus growing. We evaluated the sustainability of orange and lemon orchards, under organic and conventional farming, using an energy, environmental and economic analysis of the whole production cycle by using a life cycle assessment approach. These orchard systems differ only in terms of a few of the inputs used and the duration of the various agricultural operations. The quantity of energy consumption in the production cycle was calculated by multiplying the quantity of inputs used by the energy conversion factors drawn from the literature. The production costs were calculated considering all internal costs, including equipment, materials, wages, and costs of working capital. The performance of the two systems (organic and conventional), was compared over a period of fifty years. The results, based on unit surface area (ha) production, prove the stronger sustainability of the organic over the conventional system, both in terms of energy consumption and environmental impact, especially for lemons. The sustainability of organic systems is mainly due to the use of environmentally friendly crop inputs (fertilizers, not use of synthetic products, etc.). In terms of production costs, the conventional management systems were more expensive, and both systems were heavily influenced by wages. In terms of kg of final product, the organic production system showed better environmental and energy performances.

The monomer state of beta-amyloid: where the Alzheimer's disease protein meets physiology.

One hundred years of study have identified beta-Amyloid (A beta) as the most interesting feature of Alzheimer's disease (AD). Since the discovery of A beta as the principal component of amyloid plaques, the central challenge in AD research has been the understanding of A beta involvement in the neurodegenerative process of the disease. The ability of A beta to undergo conformational changes and subsequent aggregation has always been a limiting factor in finding out the activities of the peptide. Extensive research has been carried out to study the molecular mechanisms of amyloid self-assembly. The finding that soluble Abeta concentrations in the brain are correlated with the severity of AD, whereas fibrillar density is not /40,42/, has pointed attention toward the oligomeric forms of Abeta, which are generally considered the most toxic and, therefore, the most important species to be addressed. Despite great efforts in basic AD research, none of the currently available treatments is able to treat the devastating effects of the disease, leading to the consideration that there is more to reason than just A beta production and aggregation. Here we summarize the emerging evidence for the physiological functions of A beta, including our recent demonstration that A beta monomers are endowed with neuroprotective activity, and propose that A beta aggregation might contribute to AD pathology through a "loss-of-function" process. Finally, we discuss the current therapeutics targeting the cerebral load of A beta and possible new ones aimed at preserving the biological functions of A beta.

A peptide containing residues 26-44 of tau protein impairs mitochondrial oxidative phosphorylation acting at the level of the adenine nucleotide translocator.

Having confirmed that adenovirus-mediated overexpression of NH(2)-tau fragment lacking the first 25 aminoacids evokes a potent neurotoxic effect, sustained by protracted stimulation of NMDA receptors, in primary neuronal cultures we investigated whether and how chemically synthesized NH(2)-derived tau peptides, i.e. NH(2)-26-44 and NH(2)-1-25 fragments, affect mitochondrial function. We tested both fragments on each step of the processes leading to ATP synthesis via oxidative phosphorylation: i) electron flow via the respiratory chain from physiological substrates to oxygen with the activity of each individual complex of the respiratory chain investigated in some detail, ii) membrane potential generation arising from externally added succinate and iii) the activity of both the adenine nucleotide translocator and iv) ATP synthase. Oxidative phosphorylation is not affected by NH(2)-1-25 tau fragment, but dramatically impaired by NH(2)-26-44 tau fragment. Both cytochrome c oxidase and the adenine nucleotide translocator are targets of NH(2)-26-44 tau fragment, but adenine nucleotide translocator is the unique mitochondrial target responsible for impairment of oxidative phosphorylation by the NH(2)-26-44 tau fragment, which then exerts deleterious effects on cellular availability of ATP synthesized into mitochondria.

Assessing the Technical Effectiveness and Economic Feasibility of Pest Management Through Structural Heat Treatment: An Entomological and Economic Analysis in Four Mills in Sicily (Italy).

Heat treatments (HTs) for pest control represent a promising, fast, and non-chemical method to disinfest commodities and structures with a significantly reduced environmental impact compared with the chemical approach. An entomological and economic study has been conducted to determine the technical efficacy and economic feasibility of HT in mills that produce flour and semolina in Sicily (Italy) where, for the first time, this technique has been applied. The results obtained from the entomological analysis demonstrated that this method provided a satisfactory level of control of the following insect species: Sitophilus oryzae (L.) (Coleoptera: Curculionidae), Rhyzopertha dominica (F.) (Coleoptera: Bostrichidae), Tribolium confusum (Jacquelin du Val) (Coleoptera: Tenebrionidae), Stegobium paniceum (L.) (Coleoptera: Anobiidae), and Ephestia kuehniella (Zeller) (Lepidoptera: Pyralidae). Moreover, using precautionary assumptions in terms of revenue and cost changes resulting from the adoption of HT, the economic analysis showed a good performance of the economic indices making this technique economically feasible for the mills. Overall, the results of this study demonstrate the technical and economic feasibility of HTs which ensure to Sicilian mills a reduction of environmental impact of production process and the subsequent increase of the competitive position in the agri-food markets of the processed products.

Prion proteins leading to neurodegeneration.

Prion diseases are fatal neurodegenerative disorders related to the conformational alteration of the prion protein (PrP C) into a pathogenic and protease-resistant isoform PrP(Sc). PrP(C) is a cell surface glycoprotein expressed mainly in the central nervous system and despite numerous efforts to elucidate its physiological role, the exact biological function remains unknown. Many lines of evidences indicate that prion is a copper binding protein and thus involved in the copper metabolism. Prion protein is not expressed only in mammals but also in other species such as birds, reptiles and fishes. However, it is noteworthy to point out that prion diseases are only observed in mammals while they seem to be spared to other species. The chicken prion protein (chPrP C) shares about 30% of identity in its primary sequence with mammal PrP C. Both types of proteins have an N-terminal domain endowed with tandem amino acid repeats (PHNPGY in the avian protein, PHGGGWQ in mammals), followed by a highly conserved hydrophobic core. Furthermore, NMR studies have highlighted a similar globular domain containing three alpha-helices, one short 3(10)-helix and a short antiparallel beta-sheet. Despite this structural similarity, it should be noted that the normal isoform of mammalian PrP C is totally degraded by proteinase K, while avian PrP C is not, thereby producing N-terminal domain peptide fragments stable to further proteolysis. Notably, the hexarepeat domain is considered essential for protein endocytosis, and it is supposed to be the analogous copper-binding octarepeat region of mammalian prion proteins. The number of copper binding sites, the affinity and the coordination environment of metal ions are still matter of discussion for both mammal and avian proteins. In this review, we summarize the similarities and the differences between mammalian and avian prion proteins, as revealed by studies carried out on the entire protein and related peptide fragments, using a range of experimental and computational approaches. In addition, we report the metal-driven conformational alteration, copper binding modes and the superoxide dismutase-like (SOD-like) activity of the related copper(II) complexes.

mtDNA HVI length heteroplasmic profile in different tissues of maternally related members.

Sequencing of the homopolymeric tract of cytosines (C-stretch) in human mitochondrial HVI region usually results in a blurred pattern beyond it when a T/C transition at nt 16189 occurs: it depends on a length heteroplasmy probably arising through a replication slippage. This study aims to investigate the distribution of heteroplasmic length variants within three related individuals along maternal lineage by cloning approach. Sequencing of multiple independent clones (12--14) is sufficient to yield heteroplasmic profiles. In addition, we illustrate a direct correlation between expansion of heteroplasmy modal length and reduction of the number of adenines preceding the homopolymeric tract; this association may be useful in pedigree analysis and in forensic field for tissues comparison, single hair sample included.

[Adhesion ileus in patient with previous diagnosis of Ogilvie's syndrome]. / Occlusione intestinale su briglia in paziente con pregressa diagnosi di sindrome di Ogilvie.

A case of a 72-year-old man with abdominal pain and ileus is reported. Previous surgery for Ogilvie's syndrome had been performed. Despite conservative therapy, the occlusive symptoms worsen. Therefore the patient was submitted to surgery. At laparotomy two abdominal adhesions were found and sectioned. The differential diagnosis between mechanical ileus and pseudoobstruction for neuro-mechanics dissociation (Ogilvie's syndrome) is difficult, particularly in patients with neurodegenerative diseases.

[Prevention of post-operative pain and haemorrhage in PPH (Procedure for Prolapse and Hemorrhoids) and STARR (Stapled Trans-Anal Rectal Resection). Preliminary results in 261 cases]. / La prevenzione del dolore e dell'emorragia post-operatoria nella PPH (Procedure for Prolapse and Hemorrhoids) e nella STARR (Stapled Trans-Anal Rectal Resection). Risultati su una serie di 261 pazienti.

Intra- and early (first week) post-operative haemorrhages are the most common complications in stapled hemorrhoidectomy PPH (Procedure for Prolapse and Hemorrhoids) and in circumferential resection of the rectal prolapse STARR (Stapled Trans Anal Rectal Resection). Performing PPH and STARR we employed a gelatin based haemostatic sealant with thrombin component (FloSeal) to control intra-operative bleeding and to reduce post-operative bleeding avoiding haemostatic stitches on suture line. We report the preliminary results on 197 PPH and 64 STARR; 44 PPH (22.4%) and 27 STARR (42.2%) were treated by FloSeal. No major post-operative bleeding was observed in all patients treated by FloSeal, compared to 1.3% and 2.7% of hemorrhage respectively in PPH and STARR patients treated without sealant. Post-operative pain was less severe in patients treated by FloSeal, without a difference statistically significant. The data are preliminary and must be confirmed in prospective randomized trials in larger series.

[Rectal stenosis after stapler hemorrhoidopexy]. / Stenosi rettale dopo proctopessi con stapler per patologia emorroidaria.

We report a case of a 52-year-old woman with hemorrhoids submitted to Procedure for Prolapse and Hemorrhoids (PPH), i.e. stapled hemorrhoidopexy, using a modified Longo's technique (double purse string) to treat an associated rectocele and rectal prolapse; the STARR technique (Stapled Trans Anal Rectal Resection) was not yet codified. The post-operative course was uneventful and the patient is discharged in II p.o. day. In fifth post-operative day the patient came back with an unusual rectal stenosis due to the superior purse string. The stricture was easily resolved by 'opening' the purse string with a transanal approach in outpatient setting.

[Strangulated abdominal herniation by Ladd's band]. / Ernia intestinale strozzata su briglia di Ladd.

A case of a 64-year-old man with abdominal pain since three days, with vomiting and ileus and without previous surgery is reported. Faecal material was aspirated by a nasogastric tube; TC showed dilatation of the small bowel with the walls of the loops thickened. The patient was submitted to emergency surgery with diagnosis of intestinal infarction. At laparotomy an extensive necrosis (two meters) of small bowel was present, caused by visceral herniation by a Ladd's band. Intestinal resection was performed with latero-lateral stapled anastomosis. The postoperative course was uneventful and the patient was transferred in VII p.o. day to an hospital of his Country.

[Gangrene of Meckel's diverticulum in strangulated left inguinal hernia]. / Ernia inguinale sinistra strozzata con necrosi d'ansa e di diverticolo di Meckel.

We report a case of a 57-year-old woman admitted for abdominal pain and a not reducible mass in left inguino-abdominal region. With a diagnosis of strangulated inguinal hernia, the patient underwent urgent surgery. The surgical exploration showed a gangrenous intestinal loop with a Meckel's necrotic diverticulum. A small bowel resection (20 cm) was performed. The post-operative course was uneventful. This seems the first case reported in the literature of woman with a Meckel's diverticulum involved in a strangulated left inguinal hernia.

New approach to esophagocardiomyotomy: report of forty cases.

The major postoperative complications of esophagocardiomyotomy (ECM) for achalasia are peptic esophagitis due to gastroesophageal reflux and recurrence. According to other authors, the incidence of postoperative esophagitis is 15% ot 25%. We report the results obtained in 40 patients treated by our own surgical technique, which is based on precise anatomic and physiopathological criteria. With this technique an ECM without esophagogastric mobilization is performed via a lower thoracotomy with partial perihiatal phrenotomy. There were no intraoperative or postoperative deaths. Two patients had postoperative basal pleurisy which was cured easily in a short time. In 36 of these patients, a follow-up ranging between 15 years and 6 months revealed a complete remission of dysphagia. The patients had significant and speedy improvement in their general condition. Seven patients had substernal pyrosis when lying down, but this was relieved in a few months in six of them. In only one patient did it persist for 4 years after the operation. Ph-manometric serial control studies performed in all the patients revealed, except in one case, normal pressure and pH values in the lower esophagus. Because of these results, we consider our ECM technique very effective in the treatment of achalasia.

A new technique for ileoanal and coloanal anastomosis.

The following report includes a description of the technical details of a new surgical method for the total removal of the rectum while preserving the anal sphincter function. Seventeen patients including 11 patients with rectal carcinoma, two with diffuse polyposis involving the rectum, three with ulcerative colitis, and one with Crohn's disease of the colon and rectum have undergone operation by this method in the last 4 years. Clinical follow-up (mean 22 months) of these patients has demonstrated normal and continence for feces and gas. Postoperative manometric and electromyographic studies have also shown adequate sphincteric function. This method could be carried out either on patients in whom the total removal of the rectum is indicated or in patients with previous ileostomy or colostomy and a remaining rectal stump unsuitable for direct anastomosis.

The treatment of perforated diverticulitis by one-stage intracolonic bypass procedure.

The one-stage intracolonic bypass procedure prevents gastrointestinal secretions and fecal content from coming in contact with an anastomotic site without interrupting the intraluminal continuity of the fecal flow from proximal to distal colon. This can be achieved by the intraluminal implantation of a soft, pliable tube above the anastomotic site. Previous clinical and experimental data have indicated that the intracolonic bypass procedure can protect an anastomosis in the presence of maximal colonic loading, gross dehiscences, or fecal peritonitis. This report presents 28 patients with perforated diverticulitis, all of whom were treated by one-stage intracolonic bypass procedures. Ten of the 28 patients had peritonitis, and 18 had pericolic abscesses. Results indicate no deaths and no anastomotic leakages. Three patients (10.7%) had a complicated postoperative course. One patient with fecal peritonitis had prolonged ileus and a pulmonary effusion, and one had a myocardial infarction. Both of these patients responded to medical therapy. Another patient had a wound infection. The hospital stay ranged from 10 to 18 postoperative days. All patients passed the tubes spontaneously 2 to 3 weeks after operation. The one-stage intracolonic bypass procedure can be recommended as a viable alternative to the two- or three-stage procedures commonly used for perforated diverticulitis.

Benign biliary strictures: a review of 21 years of experience.

BACKGROUND: The treatment of patients with benign biliary strictures remains a challenge for even the most skilled biliary surgeons. Within the wide range of causes of benign biliary strictures, iatrogenic lesions represent one of the major ones. Biliary reconstruction with Roux-en-Y anastomosis remains the treatment of choice for most cases of benign biliary strictures despite recent reports about endoscopic or percutaneous management that have been quite encouraging. STUDY DESIGN: We retrospectively evaluated 194 patients who underwent surgery for benign biliary strictures over a 21-year period. The biliary strictures were classified into eight different types according to their level. The surgical procedures had been tailored mainly to the site and the extent of the structure as well as the overall status of the patient. RESULTS: Postoperative mortality and morbidity rates were 2.6 percent and 20.1 percent, respectively. The results we obtained were 79.6 percent good, 8.9 percent moderate, and 11.5 percent unsatisfactory. The mean follow-up was 9.3 years. In particular, hepati-cojejunostomy performed in low- and mid-level strictures had the best prognosis (good, 85.5 percent), while high and diffuse strictures had worse results (good, 70 percent), although with only hepaticojejunostomy according to Hepp-Couinaud, this percentage increases to 81 percent. CONCLUSIONS: Correct preoperative assessment of the site and extent of the biliary stricture is important in the choice of the gold-standard surgical procedure. Hepaticojejunostomy and hepaticojejunostomy according to Hepp-Couinaud are the treatments of choice in most instances of benign biliary strictures. Cholangiojejunostomy and hepatic resections are rarely indicated and are performed mostly for highly complicated and intrahepatic strictures. Endoscopic or percutaneous balloon dilation should be reserved for high-risk patients.

Antioxidant effect of copper(II) on photosensitized lipid peroxidation.

Unilamellar liposomes (LH) of phosphatidylcholine (PC), dispersed in phosphate buffer at pH 7 (PB), underwent lipid peroxidation and lysis with release of entrapped glucose-6-phosphate when irradiated with UVA light in the presence of 2-(3-benzoylphenyl)propionic acid (ketoprofen, KPF) or 2-(6-methoxy-2-naphthyl)propionic acid (naproxen, NAP), which were used as photosensitizers. Lipid photoperoxidation and consequent lysis were reduced when copper(II), up to 5 microM, was present in the irradiated samples. Suitable experiments were performed to evidence the species responsible for the lipid peroxidation, the copper effect on the drug photodegradation, and the mechanism of the copper antioxidant activity. The overall results suggest that the photoperoxidation was probably initiated by organic radicals obtained from the irradiation of KPF and NAP and the inhibition by copper could be attributed to its interaction with the peroxyl radicals of the drug and/or the liposomes, breaking the propagation of the radical chain.

Accumulation and interactions of beta-carotene and alpha-tocopherol in patients with adenomatous polyps.

OBJECTIVE: The aims of the present study were: (1) to determine whether short-term supplementation of beta-carotene (BC) or vitamin E (VE; alpha-tocopherol) would result in their respective accumulation in normal colonic mucosa and in adenomatous polyps; (2) to determine whether the intake of BC would interfere with the concentration of VE in these target tissues. DESIGN: Blood and colonic biopsy samples were taken before and after supplementation. SUBJECTS: Eighteen volunteers with colonic adenomatous polyps were enrolled into this study. INTERVENTIONS: The supplementation lasted for 43 days and patients were examined over the whole period. Subjects were randomised into four groups according to the four different supplementations: placebo, natural BC (25 000 IU/day), natural VE (400 IU/day), combination BC/VE. RESULTS: Initially we were aiming for recruitment of 20 patients in each group, however after 2 y of study (1997-1999), we terminated the study because of slow recruitment and analysed the data. In placebo subjects after supplementation, the plasma concentrations of BC and VE remained unchanged, however only two patients were recruited in this group and therefore we did not include this group in our final analysis. In BC group, the plasma BC concentrations increased significantly (P<0.001), while VE concentrations were unchanged. In VE group, VE concentrations increased (P<0.01) and BC did not change, and in BC/VE group both BC (P<0.001) and VE levels (P<0.01) increased significantly. After supplementation, the tissue concentration of BC in normal colonic mucosa in BC group increased significantly (P<0.01) while the VE concentration did not change. In VE group, the concentration of VE in normal colonic mucosa increased slightly but did not reach statistical significance. However, VE concentration increased significantly (P<0.05) in the polyps of this group. In BC/VE group, in which patients received the combination treatment, the BC concentration of normal colonic mucosa increased (P<0.05) but, surprisingly, the VE concentration decreased significantly (P<0.01). Interestingly in the polyps, although the BC concentration increased (P<0.01), the concentration of VE was reduced moderately but did not reach statistical significance. CONCLUSIONS: Supplementation of BC in doses used in this study may have significantly interfered with the VE concentration in the examined tissue and probably with its metabolic pathway.

Plasma (carotenoids, retinol, alpha-tocopherol) and tissue (carotenoids) levels after supplementation with beta-carotene in subjects with precancerous and cancerous lesions of sigmoid colon.

OBJECTIVES: (1) To compare tissue and plasma carotenoids status of healthy subjects and subjects with pre-cancer and cancer lesions; (2) to evaluate the effect of beta-carotene supplementation on the concentrations of other carotenoids in tissue (luteine + zeaxanthin, cryptoxanthin, lycopene, alpha-carotene) and in plasma and also retinol and alpha-tocopherol levels. DESIGN: Eighteen subjects were divided into three groups on the basis of colonoscopy and histological analytical findings: four healthy subjects (control group A); seven subjects affected by adenomatous polyps (group B with pre-cancer lesions); seven subjects suffering from colonic cancer (group C). Blood and colonic biopsy samples were taken (of colon and rectal mucosa) before and after beta-carotene supplementation in all subjects. Groups A and B received a daily dose of beta-carotene (30 mg/die) for 43 d. Group C's supplementation was terminated at the time which was performed, usually within 15 d. The tissue and plasma concentration of carotenoids, retinol and alpha-tocopherol were determined by high-performance liquid chromatography. RESULTS: The tissue concentrations of each carotenoid were similar in all the intestinal sites examined as regards groups A and B, although there was a high degree of intra individual variability within each group. Only beta-carotene made significant increases (P < 0.001) after supplementation. The subjects with cancer show tissue levels for each carotenoid lower than those of healthy subjects or subjects with polypous. The plasma levels of alpha-tocopherol did not change after supplementation while significant increases were noted of retinol, alpha-carotene (P < 0.01) and of beta-carotene (P < 0.001). CONCLUSIONS: The patients with colonic cancer seemed to undergo a significant reduction in their antioxidant reserves with respect to the normal subjects and or polyps. We can confirm that oral B-carotene supplementation induces also an increase in plasma alpha-carotene in all groups.