Role of Emerging Environmental Risk Factors in Thyroid Cancer: A Brief Review.

Environmental factors are recognized as risk factors of thyroid cancer in humans. Exposure to radiation, both from nuclear weapon or fallout or medical radiation, and to some organic and inorganic chemical toxicants represent a worldwide public health issue for their proven carcinogenicity. Halogenated compounds, such as organochlorines and pesticides, are able to disrupt thyroid function. Polychlorinated biphenyls and their metabolites and polybrominated diethyl ethers bind to thyroid, transport proteins, replace thyroxin, and disrupt thyroid function as phthalates and bisphenolates do, highly mimicking thyroid hormones. A better knowledge of environmental risks represents a very important tool for cancer prevention through true risks prevention and management. This approach is very important because of the epigenetic origin's theory of cancer. Therefore, the aim of this review was study the association between environmental agents and thyroid cancer promotion.

Hypocalcemia after thyroidectomy: iPTH levels and iPTH decline are predictive? Retrospective cohort study.

BACKGROUND: Hypocalcemia is the most common complication of thyroid surgery. The aim of this study was to determine the early predictive factors of postoperative hypocalcemia and to analyze their efficiency. METHODS: We performed a retrospective study of 345 consecutive patients who underwent total thyroidectomy at the Endocrine Surgery Department (Policlinico G. Rodolico Hospital of Catania) between January 2011 and November 2013. We measured serum intact parathormone (iPTH) levels preoperatively and 4 h after surgery. The threshold values of hypocalcemia for iPTH levels and iPTH relative decline were obtained by receiver operating curves (ROC) analysis. RESULTS: The incidence of hypocalcemia was 32.2% (111 of 345 patients). Our statistical analysis revealed that hypocalcemia rate was strongly correlated with the lower iPTH values and greater iPTH decline (P < 0.001). The threshold enabling prediction of hypocalcemia were 12,5 pg/mL for iPTH and 55,7% for relative iPTH decline. Patients with iPTH <12,5 pg/mL developed hypocalcemia in 58.6% of cases while those with iPTH ≥12,5 pg/dl in 18.8%. Among 175 patients with iPTH relative decline greater than 55,7% hypocalcemia was diagnosed in 91 cases (52%), while other 170 patients with iPTH relative decline less than 55,7% developed hypocalcemia only in 20 cases (11,7%). CONCLUSIONS: The decreased iPTH levels and increased iPTH relative decline resulted to be an accurate predictive factors of postoperative hypocalcemia. The early administration of Calcium and vitamin D in the high-risk patients should be put on in order to prevent the symptoms of hypocalcemia and to reduce the costs and duration of hospitalization.

Post-thyroidectomy hypoparathyroidism, what should we keep in mind?

AIM: Hypoparathyroidism and the resulting hypocalcemia is a common iatrogenic complication following surgical procedures to the neck, and commonly, to the thyroid gland. The aim of this study was to review the available literature to summarize current data related to the development of hypoparathyroidism after thyroid surgery. MATERIALS AND METHODS: An analysis of the surgical literature was performed using the search engine EMBASE and PubMed with particular reference to the principal risk factors related to the post-thyroid surgery hypoparathyroidism. Moreover the medical records of 345 patients, who underwent thyroid surgery at the Section of Endocrine Surgery - Department of Medical and Surgical Sciences, Advanced Technologies "G. Ingrassia" University of Catania, Italy, were also examined. RESULTS: The definition of hypoparathyroidism varies widely in literature. There is a wide range of reported incidences of transient and permanent postoperative hypoparathyroidism in literature. Extensive surgery, malignant disease and concomitant central and/or lateral neck dissection, autoimmune or Grave's' disease and re-operation represent the most recognized risk factors. A wide consensus exists about transplanting a parathyroid gland when it seems to be nonviable. DISCUSSION: Although many improvements have been done in surgical technique, hypoparathyroidism seems to be one of the most common complication after total thyroidectomy. In this study we discuss the diagnosis methods and the importance of its early prediction regardless it is transient or permanent. Recovery time is under discussion: some author consider a gland permanent injury if restoring functionality does not occur within 6 months other 12 months. To assess the parathyroid gland function some authors have been using postoperative PTH level as a useful tool for predicting hypocalcemia. CONCLUSIONS: Many efforts are required to address the problem of a consensus on best define these complications. An early low PTH level after total thyroidectomy is associated with a high risk of permanent hypoparathyroidism and normal levels usually exclude long-term parathyroid glands dysfunction. However, the cost of the PTH assay may limit its widespread application. Despite the reassuring presence of new therapeutic strategies, intra-operative preservation of the parathyroid glands is the best prophylaxis to avoid postoperative hypocalcemia after total thyroidectomy. KEY WORDS: Hypoparathyroidism, Thyroid surgery.

Epigastrium: unusual site of incisional hernia from a 5 mm trocar.

The observation of an unusual case of incisional hernia, found in the epigastric zone at the site of a 5 mm trocar incision for a cholecystectomy, has caused us to describe it and to review the literature. C.A. is a male aged 59 and He came to our attention in 2014, complaining about the presence, for about three months, a swelling in the epigastric area, without occlusive symptoms. An objective examination showed an epigastric mass at the scar of the insertion site of a 5mm trocar during the cholecystectomy operation. The patient was hospitalized and underwent traditional surgery: incision at the scar; isolation of the extruded fatty tissue, which had no sac, identified as part of the round ligament, herniated through the residual incision of the previous operation. Based on experience acquired it is useful to make careful sutures of 5 mm incisions repairing peritoneal laceration. KEY WORDS: Epigastrium, General surgery, Incisional hernia, Laparoscopy, Trocar.

How to avoid and to manage post-operative complications in thyroid surgery.

Complications of thyroidectomy are hypoparathyroidism, recurrent laryngeal nerve palsy, and hemorrhage. These complications have a low incidence. Hypoparathyroidism is the most frequent complication of total thyroidectomy. Its incidence varies between 0.5 and 65%. This complication is also visible after reoperation for recurrent disease and in patients previously treated with radioiodine. Damage to the recurrent laryngeal nerve can be temporary or permanent, unilateral or bilateral. The bilateral lesion, associated with severe episodes of breathlessness, is a rare complication (0.4%). Intraoperative control of nerves is crucial to prevent damage. The hematoma creates an obstacle to venous and lymphatic flow and consequently breathing difficulties. The preventive hemostasis during surgery is important. Therapeutic treatment is described.

Physiopathology and clinical considerations of laparoscopic surgery in the elderly.

OBJECTIVE: The marked improvements in medical technology and healthcare, lead an increasing number of elderly patients to take advantage of even complex surgical. Recently, laparoscopic surgery has been accepted as a minimally invasive treatment to reduce the morbidity after conventional surgery, and a number of studies have demonstrated the feasibility of laparoscopy with significant advantages also in the elderly. On the other side, the laparoscopic procedure has some drawbacks, including prolonged operation time and impact of carbon dioxide pneumoperitoneum on circulatory and respiratory dynamics. This paper will review the physiopathological implications of laparoscopy, as well as the current literature concerning the most common laparoscopic procedures that are increasingly performed in elderly patients. MATERIALS AND METHODS: A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting the physiopathological implications of laparoscopy in the elderly. The MeSH search terms used were "laparoscopy in the elderly", "physiopathology of laparoscopy", and "pneumoperitoneum". Multiple combinations of the keywords and MeSH terms were used with particular reference to elderly patients. RESULTS: Although laparoscopy is minimally invasive in its dissection techniques, the increased physiologic demands present particular challenges among elderly patients. CONCLUSIONS: Laparoscopy and its safety in the elderly patients remains a challenge and the evaluation of this approach is therefore mandatory. Although many studies have demonstrated the applicability and advantages of the laparoscopy also in the geriatric population, with low rates of morbidity and mortality, in elderly patients undergoing general surgical procedures the physiologic demands of laparoscopy should be carefully considered.

The thyroid disease in the elderly: Our experience.

INTRODUCTION: The number of elderly people in Italy is growing, so it is important to study the presentation of diseases in these subjects. MATERIALS AND METHODS: We selected 1362 patients who underwent thyroidectomy for different thyroid diseases from January 2008 to December 2014. The patients weredivided into two groups, according to the age. The patients aged 65 years and over were included in the group A, and the patients under the age of 65 years were included in the group B. DISCUSSION: Thyroid diseases in the elderly often present with atypical symptoms which are very similar to symptoms of the aging process. In elderly hypothyroidism occurs frequently sub-clinically and hyperthyroidism is often presented with cardiovascular symptoms. In our study we evaluated the differences in incidence of thyroid diseases in the elderly and in the younger groups of patients. CONCLUSION: The data analyzed in this study showed that in the elderly we have a reduced secretion and metabolization of thyroid hormones. The symptomatology in the elderly is nonspecific and can create a delay in the correct diagnosis.

Comparison between Focus Harmonic scalpel and other hemostatic techniques in open thyroidectomy: A systematic review and meta-analysis.

BACKGROUND: The purpose of this review was to compare the efficacy and surgical outcomes of total thyroidectomy between the Focus Harmonic scalpel (Ethicon, Cincinnati, OH) and other hemostatic procedures. METHODS: An extensive search was conducted using the PubMed and Cochrane databases from January 2008 to October 2014. Operating time, blood loss, pain, complications, and hospital stay were evaluated. RESULTS: When compared with conventional techniques or LigaSure Precise Vessel Sealing System (Medtronic, Minneapolis, MN), the use of the Focus Harmonic scalpel reduced operative time by 22,428 minutes and blood loss by 13,914 mL. Length of hospital stay was significantly shorter in the Focus Harmonic scalpel group with a mean reduction of 0.410 days. CONCLUSION: According to our meta-analysis, when comparing the Focus Harmonic scalpel versus conventional techniques, it seems evident that the use of this device in thyroid surgery is associated with a mean reduction in operating time, blood loss, and hospital stay, without any increase in pain and complications. There was no appreciable difference between the Focus Harmonic scalpel and the LigaSure Precise Vessel Sealing System. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1578, 2016.

Synchronous ileal neuroendocrine tumor: diagnosis and treatment. A case report and review of the literature.

INTRODUCTION: The majority of neuroendocrine tumors (NET) are located in the gastrointestinal tract (67.5%) and in the bronchopulmonary (25.3%). CASE REPORT: CA, female, 42 years old, profuse diarrhea about two months, cramping for increased peristalsis, vomiting and weight loss. The patient, diagnosed with ileal neuroendocrine tumor, by colonoscopy with biopsy of lesion, therefore came in our unit to be subjected to surgical therapy. Plasma assay Chromogranin A was performed: 160 ng / ml (nv: 15-100 ng / ml). The patient underwent surgery of right hemicolectomy. DISCUSSION: Neuroendocrine tumors although are rare diseases, have an increasing impact, probably by virtue of improved diagnostic methods. In case of profuse diarrhea should be suspected a neuroendocrine tumor. Certainly the diagnosis of certainty is given by histological examination (biopsy or resected nodule). CONCLUSION: After surgical excision is necessary to perform the follow-up of chromogranin A, and, if not executed, perform nuclear medicine examinations such as Octreoscan and PET. KEY-WORDS: Chromogranin A, Neuroendocrine tumor, Octreoscan.

Thyroidectomy: Natural drainage or negative drainage? Experience with randomized single-center study.

AIM: The aim is to investigate, in relation to the volume of blood drained, which type drainage to use after thyroidectomy natural drainage or negative drainage. MATERIAL OF STUDY: 141 patients who underwent total thyroidectomy for multinodular thyroid disease between 22 November 2012 and 7 November 2013 were included in the present study. For the 141 patients a randomized method was used with closed circuit natural drainage (59 cases) or negative drainage (82 cases). The evaluation of the drained volume was performed 24, 48 and 72 hours following surgery. RESULTS: The amount of blood drained during the first 24 hours of the postoperative period averaged 78.59 ml in patients with a negative drain and 54.24 ml in those under natural drainage. After 48 hours, the total volume in the first group was 117.98 ml, while in the second group it was 85.18 ml. In cases where the observation was prolonged up to 72 hours, the average volume was 217 ml in the 10 cases of negative drainage and 117.5 ml in the 4 cases of natural drainage. CONCLUSION: The difference in blood volume observed between the two groups of patients with natural drainage and negative drainage, leads us to conclude that the best drainage in thyroidectomy is the natural one, diverging from the older concept of the use of negative drainage in superficial cavities.

Cystic pancreatic neuroendocrine tumors: To date a diagnostic challenge.

OBJECTIVE: Cystic PNETs are an uncommon neoplasms increasingly detected in current clinical practice which often present a diagnostic challenges to both the experienced radiologist and pathologist. The aim of this study was to review the available literature to summarize current data that compare and evaluate both the clinical and pathologic features of cystic pancreatic neuroendocrine tumors. MATERIALS AND METHODS: A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting on cystic pancreatic neuroendocrine tumors. The MeSH search terms used were "cystic pancreatic neuroendocrine tumors", "endocrine neoplasms", and "pancreatic cysts". Multiple combinations of the keywords and MeSH terms were used. RESULTS: The clinical evaluation of cystic pancreatic lesions appears to suffer from same limitations despite the improvement in the diagnostic tools. Subsequently, we highlight diagnostic pitfalls and differential diagnosis of these cystic tumors. In this review we discuss current advances in the application of the imaging modalities and characteristics features with special emphasize on endoscopic ultrasound (EUS), and EUS guide fine needle aspiration (EUS-FNA). CONCLUSIONS: Cystic neuroendocrine tumor in the pancreas underlines the clinical impact of endoscopic ultrasound in the work-up of patients with unclear lesions in the pancreas. EUS-FNA cytology and cyst fluid analysis is a useful adjunct to abdominal imaging for the diagnosis of pancreatic cystic lesions. Due to the evident diagnostic difficulties, we hypothesize that cyst fluid characteristics, including cytomorphological features, is the most accurate test to achieve a preoperative diagnosis and to provide a basis for prognostic prediction.

Management of patients with rectus sheath hematoma: Personal experience.

BACKGROUND/PURPOSE: Rectus sheath hematoma (RSH) is a rare clinical entity. It can be mistaken for other intra-abdominal disorders, which can result in diagnostic and therapeutic difficulties. This study was undertaken to analyze the clinical presentation, diagnostic modalities, and management of patients affected with RSH. METHODS: Between January 2008 and June 2011, eight patients (5 men and 3 women with a mean age of 53 years) with RSH were evaluated according to demographic characteristics, clinical and radiological findings, and methods of treatment. RESULTS: Six patients developed RSH after anticoagulant therapy; one after local trauma, and one after laparoscopic intervention. Six patients were treated nonsurgically; one patient underwent embolization of the inferior epigastric artery and one underwent ligation of the bleeding vessel. The average hospital stay was 6 days. There were no mortality or thromboembolic complications. CONCLUSION: RSH is a rare nonneoplastic entity that is usually associated with abdominal trauma and/or anticoagulant therapy. The gold standard for diagnosis is computed tomography, and ultrasonography can be used in follow-up. The treatment of choice is nonsurgical therapy because RSH is a self-limited condition. Surgical intervention should be reserved for cases with hemodynamic instability.

The use of FOCUS Harmonic scalpel compared to conventional haemostasis (knot and tie ligation) for thyroid surgery: a prospective randomized study.

Haemostasis is crucial in thyroid surgery to avoid intraoperative and postoperative complications. In the present study, we evaluated the efficiency and the safety of Harmonic scalpel when compared to conventional suture ligation in open total thyroidectomy. We enrolled 265 patients who underwent total thyroidectomy for multinodular disease since October 2011 up to October 2013. They were randomized into two groups: 141 in group HS (Harmonic Scalpel), 124 in group CT (Conventional tecnique). We recorded the following data: operative time, post-operative blood loss, length of hospital stay and complications. The patients were monitored for 48 hours after surgery. Several differences were observed between the two groups (HS vs CT): the use of Harmonic scalpel was associated to a significant reduction of surgical operative time (110 min in CT vs 79.36 min in HS, p = 0.00001) and also associated to a lower blood loss (97.38 ml in CT vs 68.72 ml in HS, p = 0.00001). The length of stay was significantly shorter in the HS group (2.75 days in CT vs 1.93 days in HS) Complication rate was similar in the two groups. According to our experience, the Harmonic scalpel represents a safe alternative to conventional haemostasis in thyroid surgery, allowing for a significant reduction of operative time, blood loss and hospitalization. The rate of complication demonstrated no significant difference among the two groups.

Spontaneous rupture of an umbilical hernia in a cirrhotic patient with ascites A case report and review of the literature.

The authors, report a case of spontaneous rupture of an umbilical hernia in a cirrhotic patient with ascites and perform a literature review. Their results and the published data suggest that it is preferable to perform elective surgery after stabilization of the ascites and the patient's general condition in order to prevent complications and mortality. KEY WORDS: Ascites, Hernioplasty, Spontaneous hernia rupture.

[Radiation exposure and thyroid cancer]. / Radiazioni ionizzanti e cancro tiroideo.

Thyroid cancer is the most common malignant tumor of the endocrine system. The most frequent type of thyroid malignancy is papillary carcinoma. Thyroid cancer's incidence rates have increased over the last three decades throughout the world. Numerous studies have documented that radiation exposure is a well-established risk factor for the thyroid cancer. It has been reported that exposure to external medical radiation or to external and internal radiation from atomic bomb explosions, nuclear tests or nuclear accidents leads to an increased risk for thyroid cancer. The risk of thyroid cancer is maximal during the first years of life and decreases with increasing age at exposure due to morphologic and functional heterogeneity in the thyroid tissue of children and adults. Also it has been indicated that iodine deficiency increases the risk of the thyroid cancer related to radioactive iodines in case of exposure to radioactive iodines in childhood and the stable iodine supplementation reduces this risk. Ionizing radiation produces a range of mutations in irradiated cells of the thyroid. The prevalence of RET/PTC mutations is significantly higher in papillary carcinomas from childhood patients with the precedent history of radiation.

[Neoplastic small bowel obstruction: our experience with 21 cases and review of the literature]. / Occlusione neoplastica del tenue: nostra esperienza e revisione della letteratura.

Small bowel tumours are rare, representing 0.3% of all cancers. The main problem with these tumours is that they induce vague, non-specific symptoms, causing a delay in diagnosis, which is often reached in cases of acute complications such as intestinal obstruction. Moreover, the small bowel is often involved secondarily by tumours that actually start from adjacent organs or by processes of peritoneal carcinomatosis, conditions which are responsible for a distinct worsening of the prognosis (up to 70% mortality). The aim of the study was to define the indications and the most appropriate surgical treatment modalities depending on the presentation of the small bowel tumour. At the Emergency Surgery Unit of the Vittorio Emanuele, Ferrarotto and S. Bambino Hospital in Catania 21 cases of intestinal obstruction caused by small bowel tumours were observed out of a total of 335 patients affected by intestinal occlusion (1.6%). Thirteen patients (62%) had already undergone abdominal surgery for a malignant neoplasm. All patients underwent plain abdominal X-ray which showed air-fluid levels; 14 (66%) were additionally studied by CT scans. Thirteen patients were operated on immediately on the day of admission, while the other 8 were initially treated conservatively. The small bowel was the primary site of the neoplasm only in 3 cases; in the other 10 it was secondarily involved by tumours originating from adjacent organs or by peritoneal carcinomatosis. In 8 cases an intestinal resection was accomplished together with removal of the involved organs, while in the 5 cases of carcinomatosis simple diverting procedures were carried out. Of the 8 patients initially treated conservatively, 6 were subsequently submitted to diverting operations because of persistence of the occlusive status. Nine patients had postoperative complications (47%) and another 3 died (14%). In conclusion, intestinal obstruction is a frequent complication of small bowel tumours, especially if they are in the final stages. Intestinal resection offers a good chance of recovery in cases--unfortunately rare--of confined tumours; in the other instances it is preferable to perform diverting procedures and subsequently refer the patient to the oncologist in order to plan adjuvant therapy, if possible.

[Perforated jejunal diverticulum. A case report]. / Diverticolo digiunale perforato. Caso clinico.

The Authors report on a case of a 69 years old woman with an acute peritonitis secondary to a perforated jejunal diverticulum, treated by laparotomy and intestinal resection with end-to-end anastomosis in one layer. The patient was dismissed after seven days, in good general conditions. Jejunal diverticula occur in around 1% of general population. They are usually asymptomatic; sometimes they give origin to dyspepsia or acute manifestations. These are due to complications at the site of the diverticulum like bleeding, occlusion and acute infection with perforation and peritonitis, as occurred in our patient. The main risk in diverticular complications is to prolong the interval between admission of the patient and surgical treatment, favouring the initiation of hypovolemic or septic shock. For these reasons, in most recent years, C.T. and, in case of bleeding, capsule endoscopy, were used in the diagnostic pre-operative work-up. The surgical technique is jejunal resection with direct anastomosis, leaving percutaneous drainage only for patients with an abscess, in poor general conditions for a narcosis.

Cytomegalovirus and Clostridium difficile ischemic colitis in a renal transplant recipient: a lethal complication of anti-rejection therapy?

Intestinal ischemia is reported to be the most common gastrointestinal complication of renal transplantation and a potential cause of morbidity and mortality. The recent use of more potent immunosuppressive drug regimens has reduced the incidence of acute rejection, increasing the incidence of potentially fatal infectious complications, such as clinically important cytomegalovirus (CMV) infection. A 42-year-old kidney transplant recipient experienced on postoperative day 10 a dehiscence of the ureterovesical anastomosis, associated with a 7-cm longitudinal tear graft on the lower pole of the kidney and an ureteral ischemia. A graft biopsy demonstrated a mild acute rejection for which the patient received an unsuccessful administration of steroids, with progression of the rejection, so that 1 mg/kg/day antithymocyte globulin was administered. Two days later the patient presented with fever (39.5 degrees C), diffuse abdominal pain with tenderness and bloody diarrhea, and diagnosis of CMV colitis was achieved; rectal samples were taken for histologic examination, and Clostridium difficile toxin was isolated. A subtotal colectomy with Hartmann's procedure was performed, but the patient died 13 days later of a multiple organ failure. The risk of lethal CMV colitis is increased in patients being treated with anti-rejection therapy for severe acute rejection; the occurrence of simultaneous infection, such as pseudomembranous colitis, usually characterized by a favorable prognosis, increases the mortality rate in these patients.

[The treatment of blunt abdominal trauma. Personal experience]. / Il trattamento dei traumi addominali chiusi. Nostra esperienza.

BACKGROUND: Aim of the study is to work out diagnostic and therapeutic guidelines in blunt abdominal trauma, considering our modern diagnostic tools and actual international propensity for non-operative treatment. METHODS: Seventy five patients observed during the last three years at Emergency Surgery Unit of "Vittorio Emanuele" Hospital in Catania, Italy. All patient underwent, after blood tests, abdominal ultrasound and/or CT showing one or more abdominal lesions in 52 (69.3%) of them. Out of these 52 patients with organ injuries, 29 (55.8%) underwent surgery, while 23 (44.2%) non-operative treatment: the most injured organs were spleen (34 cases), liver (18 cases) and kidneys (4 cases). On the basis of haemodynamic conditions of the patients and of the results of abdominal ultrasound and/or CT the Authors decided between surgical or non-surgical treatment, working out in the meantime their diagnostic-therapeutic guidelines. In Authors' experience, while for splenic injuries the majority of patients was operated (splenectomy), for hepatic injuries non-operative treatment was preferred, as well as for all renal injuries. RESULTS: Two patients (2.6%) died because of hypovolemic shock secondary to an high-grade hepatic trauma associated with d.i.c.; both patients reported other major lesions of, respectively, chest and brain. Other 4 patients developed postoperative complications: 1 patient a pleuritis and 3 patients a wound infection. All these patients recovered with antibiotics and, where necessary, repeated change of medical dressing. The other 69 patients recovered completely, without any significant complication. CONCLUSIONS: The study of personal experience of the last three years on abdominal blunt trauma (75 patients) has allowed the Authors to work out diagnostic-therapeutic guidelines, which are based mainly on patients' haemodynamic conditions and on sonographic and CT results. The applications of this protocol has allowed the Authors during last 12 months to practice more frequently the non-operative treatment, avoiding unnecessary surgical operations, sparing the patient organic deficit and possible intra and post-operative complications.

[Crohn's disease in the elderly]. / La malattia di Crohn nell'anziano.

AIM OF THE STUDY: To define the characteristics of Crohn's disease in the elderly, basing on our own and other Authors' experience. CASISTIC: During last 10 years, 46 patients affected by Crohn's disease were observed at Emergency Surgery Unit of "Vittorio Emanuele" Hospital in Catania (Italy). Of these patients, 4 (8,6%) were old: 3 with an ileal location and 1 with a colic location of the disease. This latter patient was cured only by medical treatment because of the paucity of clinical manifestations of the disease. The other 3 patients underwent surgical treatment (2 ileocecal resections and 1 ileal resection). RESULTS: Up to date all 4 patients are alive and in good general conditions. Only one patient had recurrence of disease, but recovered after medical treatment. DISCUSSION: Crohns disease in the elderly, although usually similar to the adult form, differs for some aspects. Concerning pathology, in the old patient fibro-sclerotic and ulcerative aspects predominate and the colic location is more frequent; clinically, in the elderly the occlusive (two out of our four cases) and haemorrhagic complications are seen more than in young-adults; sometimes the symptoms are poor so that a diagnostic delay occurs, with a possible worsening of prognosis. Regarding the treatment of Crohn's disease it, especially in old patients, must be medical, excluding peculiar situations which need surgical treatment (acute complications, unresponsiveness to drugs). Most frequent operations are segmentary ileal resections and ileocecal resections, as it happened in our experience. Post-operative morbidity and mortality are higher in the elderly, comparing to adult rates, because of more frequent cardiac and respiratory complications, due usually to pre-existing conditions. CONCLUSIONS: Crohn's disease affects old patients in 10-15% of cases. In this age-group it is mandatory to suspect the presence of this disease even if the clinical exam is poor, so that specific diagnostic investigations are carried out in order to avoid lost of time, which can be responsible of an unsuccessful treatment. The treatment is essentially medical; surgery, if necessary, must be as most conservative as possible.