Gluten-free diet: a new strategy for management of painful endometriosis related symptoms?

AIM: Pelvic pain affects 4% to 39% of women and accounts for 10-40% of all outpatient gynecologic visits. The etiology of painful endometriosis-related has not been fully delineated. No studies have been published concerning gluten-free diet administered to achieved relief of painful symptoms endometriosis-related. The aim of this retrospective study was to evaluate the effectiveness for the outcomes of endometriosis-related pain and quality of life of gluten-free diet in a follow-up of 12 months in patients with chronic pelvic pain endometriosis-related. METHODS: Two hundred seven patients with severe painful endometriosis-related symptoms entered the study. At enrolment time, the baseline values of painful symptoms were assessed by Visual Analogue Scale (VAS) for dysmenorrhoea, non-menstrual pelvic pain, and dyspareunia. According to VAS, pain severity was scored from 0-10; 0 indicating the absence of pain, and 1-4, 5-7 and 8-10 mild, moderate and severe respectively. A gluten-free diet was submitted to all patients and a new evaluation was performed after 12 months of diet. Student t test was used for statistical analysis. RESULTS: At 12 month follow-up, 156 patients (75%) reported statistically significant change in painful symptoms (P<0.005), 51 patients (25%) reported not improvement of symptoms. No patients reported worsening of pain. A considerable increase of scores for all domains of physical functioning, general health perception, vitality, social functioning, and mental health was observed in all patients (P<0.005). CONCLUSION: In our experience, painful symptoms of endometriosis decrease after 12 months of gluten free diet.

Retroperitoneal sepsis with mediastinal and subcutaneous emphysema complicating stapled transanal rectal resection (STARR).

The STARR procedure was introduced a few years ago for the treatment of obstructed defaecation syndrome secondary to internal rectal intussusception and rectocele. We present a case of severe retroperitoneal sepsis with mediastinal and subcutaneous emphysema complicating STARR, treated by transperineal pelvic drainage and a loop sigmoid colostomy.

Localization of S-100 protein in Müller cells of the retina--2. Electron microscopical immunocytochemistry.

The cellular and subcellular distribution of S-100 protein was investigated at the ultrastructural level in the rat retina by the immunocytochemical PAP method. S-100 appeared to be localized in the cytoplasm and nucleus of Müller cells, offering conclusive evidence that in the mammalian retina, the protein is confined to glial cells. S-100, as a marker for Müller cells, may be a useful tool in order to study the cytoarchitecture of the retina in normal as well as in pathologic conditions. In addition, the retina may represent a suitable model for further investigation on the biologic role of S-100.

The expanding utility of endoluminal ultrasonography in the management of rectal cancer.

BACKGROUND: This study assessed the ability of endoluminal ultrasonography (ELUS) to determine extent of local invasion and lymph node (LN) metastasis of primary rectal tumors, to assist in ELUS-guided pelvic LN biopsies, and to assess invasion of locally recurrent rectal cancers compared to computed tomography (CT). METHODS: Eighty-one patients with rectal adenocarcinoma (n = 67) or villous adenoma of more than 3 cm (n = 14) underwent ELUS with a 360-degree 7.0-MHz transducer For LN biopsy (n = 10), ELUS was used with an 18-gauge core biopsy needle passed transrectally. ELUS and CT were compared in 14 locally recurrent tumors. RESULTS: Staging for primary tumors (ELUS compared with pathologic examination, TNM system) revealed ELUS accurately predicted wall penetration and LN status with 95% confidence intervals of 0.88 to 0.99 and 0.87 to 0.99. Eight cancers were overstaged, and two were understaged by ELUS. ELUS-guided LN biopsy revealed carcinoma (n = 3) or lymphoid tissue (n = 3) in six of 10 patients. Extent of pelvic organ involvement was predicted in 11 of 14 ELUS and eight of 14 CT examinations in recurrent rectal cancer. CONCLUSIONS: ELUS is accurate in staging rectal cancers, can guide biopsies of pararectal LNs, and may be more reliable than CT in assessing local recurrence. The role of ELUS in the management of rectal cancer is expanding.

[Revascularization of the corpora cavernosa in vasculogenic impotence]. / Rivascolarizzazione dei corpi cavernosi nell'impotenza vasculogenetica.

The vasculogenic erectile impotence, caused by occlusion and/or stenosis of arteries supplying the penis, is the most common cause of erectile failure in men over 40 years. The vasculogenic impotence is more found by peripheral vasculopathies like diabetes mellitus and nicotine abuse. It is important that the precise site of vascular lesion is established with selective arteriography of the hypogastric-internal pudendal axis. The specific aim of surgery is to increase the cavernosal arterial perfusion pressure and blood inflow in patients with vasculogenic erectile dysfunction secondary to pure arterial insufficiency. There have been multiple revascularization techniques described for the treatment of proximal or distal occlusion with variable results. Microsurgery is important for distal lesions and we think that the best candidates for the Michal II procedure seem to be those with localized obstruction of the internal pudendal, while venous arterialization is the preferred procedure for patients with pathological cavernous or dorsal penile arteries. In this paper the most important procedures to restore physiological erection are presented; however no single revascularization procedure has been generally accepted as a definitive answer to this problem. There is a need for further prospective studies with longer follow-up and more objective investigations.

[Radiotherapy of cancer of the uterine cervix and successive appearance of new malignant growth in the irradiated field]. / Radioterapia per carcinoma del collo dell'utero e successiva comparsa di nuove neoplasie maligne nel campo di irradiazione.

Among the late complications of high-dosage pelvic radiotherapy for cervical cancer, anorectal and bladder malignancies are sporadically reported in the literature. In this study the possible relationships of previous radiotherapy with late appearance of neoplasms are analyzed and in particular post-radiotherapy interval, dosage and type or irradiation to the cervical area. The mechanisms or neoplastic transformation or irradiated tissues are also studied. Three clinical cases or women irradiated in the past because or cervical cancer and recently treated at our surgical Division for the appearance or four new pelvic malignancies in the irradiated field (three rectal and one bladder cancer are presented. In conclusion, the possible cause-effect relationships between previous radiotherapy and subsequent appearance of neoplasms are analyzed as well as the potential therapeutical consequences or considering these women high-risk subjects. The usefulness or recruiting women with history or previous radiotherapy for cervical cancer in a strict follow-up program (ultrasonography, cytology and endoscopy) is suggested in order to make an early diagnosis of the new pelvic malignancy with a better possibility or treatment.

[Clinico-pathological study of microcarcinoma of the thyroid]. / Studio clinico-patologico del microcarcinoma della tiroide.

We have analysed the results of surgical treatment for microcarcinoma of the thyroid (MCT). In sixteen patient clinical and follow-up data were retrospectively evaluated during a 35.1-month follow-up. Thyroid hyperfunctional state us was present in two subjects. A single nodule was detected by echotomography in 11 patients, while multinodular diffuse goitre was revealed in 3 patients. In the last two subjects, thyroid gland appeared completely normal at ultrasonography, despite laterocervical lymph node metastases. Fine-needle aspiration biopsy was performed in 6 patients and its diagnostic accuracy was high (83,3%). MCT was classified as "incidental" in 12 patients and "occult" in the remaining 4 patients. Eight subjects underwent total thyroidectomy and 8 hemithyroidectomy plus isthmectomy. No postoperative complications were recorded. In 10 patients MCT histotype was papillar adenocarcinoma, in 5 was follicular adenocarcinoma and in the remaining case it was medullary carcinoma. Goitre was associated in 75% of the cases. Only in a patient disease progressed to death because of hematogenous metastases. In conclusion, we believe that incidental MCT is a low-grade malignancy with a benign biological behaviour. Occult MCT is a potentially lethal disease. We did not observe differences in the long-term results between different surgical treatments of MCT.

[Role of radioisotopic lymphoscintigraphy in postphlebitic syndrome of the legs]. / Ruolo della linfoscintigrafia radioisotopica nella sindrome postflebitica degli arti inferiori.

Post-phlebitis syndrome of the lower limbs is a set of symptoms that follow a state of phlebostasis and phlebolymphostasis with consequent oedema and tissue distress. We submitted 36 patients with post-phlebitis syndrome of the lower limbs to radioisotopic lymphoscintigraphy for the purposes of evaluating the vicariant function of the lymphatic system and the possible role of the lymphatic system in the genesis of dermo-epidermal abnormalities. The average age of the patients was 53.2 years (range: 43-69 years; M:F ratio: 0.50). The control group consisted of 6 healthy subjects. The average duration of the post-phlebitis syndrome in the patients studied was 8.5 years. We excluded from the study patients in whom a central cause was identified as being responsible for the pathogenisis of the oedema of the lower limbs. In addition, patients with obliterant arteriopathy were also excluded. Venous pathology was evaluated first clinically and then investigated by continuous-wave Doppler. As a first step, venous pressure was measured by Doppler phlebomanometry in clino- and orthostatism. All patients underwent radioisotopic lymphoscintigraphy with microcolloids using the Rijke technique. Radioactivity was monitored by means of a computerized gamma-camera. We classified the pathological findings of radioisotopic lymphoscintigraphy as follows: 1) delayed transit; 2) obstacles; 3) star-shaped superficial collateral lymphatic circulations; 4) lymphocoele or cutaneous lakes. A significant difference was detected (p < 0.05) between the pressure values in the post- phlebitis lower limbs and the pressure values in normal subjects. Combining the results of our measurements we recorded delayed transit in 5 patients (69.5%). This latter group included the cases with the severest forms of post-phlebitis syndrome. Therefore, better knowledge of the pathophysiology of the lymphatic system would appear to be useful in order to understand the origin and evolution of oedema of the lower limbs of patients with post-phlebitis syndrome. To this end, radioisotopic lymphoscintigraphy may be useful as a first-level examination in order to evaluate the capacity and efficiency of the lymphatic system.

[Minimal carcinoma of the stomach. Observations on the histogenesis of gastric carcinoma]. / Il "carcinoma minimo" dello stomaco. Osservazioni sulla istogenesi del carcinoma gastrico.

A six case series of "minute gastric cancer", with maximum dimension of less than 5 mm., is presented by the authors. All these cases were studied clinico pathologically by endoscopy and preoperative biopsy and were controlled by detailed pathological examination of the operative specimens, specially in order to assess the incidence of intestinal metaplasia and dysplasia of the gastric mucosa. Histogenetically the authors appreciate a relation between intestinal metaplasia of the gastric mucosa and the intestinal type of the gastric cancer, in according to the Lauren classification. This relation is not evident between intestinal metaplasia and diffuse histological type of gastric cancer. Mucosal dysplasia is the alteration most often found in the gastric mucosa of patients with gastric cancer. Dysplasia of the gastric mucosa should be considered the most important factor related to the development of the gastric cancer.

[Retrospective analysis of the use of prophylactic drainage of the pelvis after anterior resection of the rectum]. / Analisi retrospettica sull'uso del drenaggio profilattico della pelvi dopo resezione anteriore del retto.

Although the use of drains is common in clinical practice, its real role in the prophylaxis and therapy of postoperative complications is still not clear. In the literature we can find both supporters of drains, and many opponents who consider their use unnecessary and sometimes even dangerous. In fact, during new experimental and clinical studies, it was impossible to determine the usefulness of prophylactic abdominal drain, at least in the case of colo-rectal anastomosis, it has been demonstrated that use of drains limits the risks of an anastomotic leakage but, in some cases, the same drains could be the cause of some of the complications that should be avoided. Although there is a considerable theoretical and practical evidences in favour of drainage, the dispute about "to drain or not to drain" the peritoneal cavity after elective colo-rectal surgery remains open. This retrospective study made on 150 patients operated on elective surgery for rectal cancer demonstrates that prophylactic drain does not significantly influence the general rate of leakage (3.15% for group A and 5.45% for group B, p > 0.1); in two of the three fistulas in patients with drains, the drains have permitted the diagnosis, but have not permitted the reduction of the number of operations for fistulas.

[Primary lymphoma of the thyroid gland. Review of the literature and presentation of a clinical case]. / I linfomi primitivi della tiroide. Revisione della letteratura e presentazione di un caso clinico.

Primary malignant lymphoma of the thyroid is a very uncommon disease and represents approximately 5% of all thyroid malignant neoplasms. The Authors report a case whose clinical and histopathological features are discussed and compared with those of previously published series. Primary malignant lymphomas raise a number of issues: abrupt onset, age and sex patterns, histological typing (virtually 100% of cases are non-Hodgkin lymphomas), differential diagnosis with either Hashimoto's chronic thyroiditis (often associated with thyroid primary lymphomas) or genuine anaplastic carcinoma of the thyroid. Routine histological study can be complemented by immunohistochemistry. The treatment of choose is total thyroidectomy plus radiotherapy in cases where radical surgery is possible, or radiotherapy alone which usually carries good results.

[Endoscopic polypectomy and adenoma-carcinoma sequence of the large intestine. Considerations on personal case series]. / Polipectomia endoscopica e sequenza adenoma-carcinoma nel grosso intestino. Considerazioni su casistica originale.

Since the introduction of colonoscopic polypectomy, the management of colonic polyps has dramatically changed. What once was a major transabdominal operation now is a routine therapeutic endoscopic procedure. To test the hypothesis of the adenoma-carcinoma sequence histopathologic features of polypoid lesions are retrospectively evaluated. In our experience with 566 polypectomies 430 adenomatous polyps, 71 hyperplastic, 58 inflammatory polyps, and 4 juvenile lesions are reported. Only adenomatous polyps showed dysplasia. Overall, severe and moderate dysplasia was respectively observed in 6.7% and 23% of the adenomas. Infiltrating carcinoma was present in 2.2% of the cases. Villous adenomas showed high rates of severe dysplasia (37%) and invasive carcinoma (18%). Location and sex did not seem to have a role in the malignant potential of adenomas.

[Gastric polyps: histogenetic considerations and therapeutic trends]. / I polipi gastrici: considerazioni istogenetiche ed orientamento terapeutico.

The Authors report their series of 86 patients with gastric polyps, observed from 1986 to 1989. Basing on the literature data the lesions were divided in A) inflammatory polyps, B) hyperplastic polyps, C) adenomatous polyps and 27, 49 and 10 lesions, were respectively found for each type. Particular attention was given to the association between intestinal metaplasia and gastric dysplasia for each type of polyp. A significant prognostic value as a precancerous lesion was recognized only to dysplasia. Therapeutic trend for each single polyp, based on the histologic type, is suggested.

[Solitary ulcer of the rectum: a report of a clinical case associated with rectal prolapse]. / Ulcera solitaria del retto: presentazione di un caso clinico associato a prolasso rettale.

Solitary ulcer of the rectum is an unusual condition occurring more often in young adults. Unfortunately the term is rather confusing, since the lesion may not necessarily be solitary, nor be confined to the rectum; moreover, it may be polypoid rather than ulcerating. The etiology is uncertain, but chronic constipation and fecal impaction could play a role. Today most authors believe solitary ulcer syndrome is a distinct clinical inflammatory manifestation associated with rectal prolapse. Surgical treatment of the prolapse is usually followed by a recovery of the solitary rectal ulcer.

Immunohistochemical study of the corpora cavernosa of the human clitoris.

The microarchitecture of the corpora cavernosa of the human clitoris was investigated by immunohistochemistry. The distribution pattern of the nerve network was demonstrated by S-100 and neuron specific enolase immunoreactivity. Vascular and nonvascular muscle cells were identified by desmin and/or vimentin expression, and fibroblasts and endothelial cells by vimentin immunoreactivity. The findings show that tissue organisation in the corpora cavernosa of the clitoris is essentially similar to that of the penis except for the absence of the subalbugineal layer interposed between the tunica albuginea and erectile tissue. This has functional implications, suggesting that the clitoral erection cycle differs from that of the penis.

Delorme's operation and sphincteroplasty for rectal prolapse and fecal incontinence.

Clinical and manometric results of Delorme's operation and sphincteroplasty were assessed retrospectively in patients undergoing this procedure for fecal incontinence and rectal prolapse. A series of 33 patients (11 males, 22 females; aged 18-83 years, mean 59) with external rectal prolapse were treated by Delorme's operation between 1989 and 1996. Mean follow-up was 39 months (range 7-84). Sphincteroplasty was associated in 12 cases with severe fecal incontinence due to striated muscle defects. Good results were achieved in 27 patients (79%); prolapse recurrence was observed in 6 (21%), the mean recurrence time being 9 months (range 1-24 months). There were no postoperative deaths. Minor complications occurred in 15 patients. Changes in preoperative and postoperative manometric patterns were as follows (mean +/- SEM): voluntary contraction from 59 +/- 6.9 to 66 +/- 7.1 mmHg (P = 0.05), resting tone from 33 +/- 5 to 32 +/- 4.3 mmHg, rectal sensation from 59 +/- 5 to 61 +/- 5.2 ml of air (n.s.). A solitary rectal ulcer syndrome was detected in five patients. The histological pattern demonstrated pathological changes in 40% of cases. Fecal incontinence was resolved in 6 of 20 cases (30%) and chronic constipation in 4 of 9 (44%). Failure (n = 3) was related primarily to postoperative sepsis. The incontinence score showed a mean improvement of 35% decreasing, from 4.5 +/- 0.39 to 2.9 +/- 0.44 after surgery (P < 0.01). In conclusion, Delorme's procedure did not lead to constipation and improved anal continence when associated with sphincteroplasty.

[Calcifications of the prostate: a transrectal echographic study]. / Le calcificazioni della prostata: studio con ecografia transrettale.

Prostatic lithiasis is a well know phenomenon. It has little clinical significance and is not easily shown by conventional radiography, which has poor sensitivity and specificity. The authors have studied 612 patients with both suprapubic and transrectal US in order to 1) assess US sensitivity and specificity and 2) report the frequency, spatial distribution, number and features of prostatic calcifications with special emphasis on differential diagnosis between prostatic neoplasms and chronic prostatitis. The authors have also studied the relationship between morphology and symptoms and the results agree with those reported in the scanty literature. The authors conclude that the parameters studied are directly related to age, except for a younger group with clear evidence of genital inflammation. The authors emphasize the impossibility to correlate morphology of prostatic calcifications with pathologic conditions: there are no specific symptoms clearly connected with calcification even though the inflammation is often associated with calcifications.

Resident research award: tumor necrosis factor alpha selectively enhances growth and cytotoxic activity of tumor infiltrating lymphocytes from human colorectal cancer.

Adoptive immunotherapy with tumor-infiltrating lymphocytes (TIL) and interleukin-2 (IL2) can induce regression of tumor metastases in animal models and in human metastatic malignant melanoma. We investigated the potential of colorectal cancer TIL as a source of killer cells and the effect of tumor necrosis factor alpha (TNF alpha) in combination with IL2 on their cytotoxic activity. Tumor-infiltrating lymphocytes were isolated from surgical specimens using a mechanical and enzymatic dissociation process. Autologous lamina propria mononuclear cells (LPMC) were used as control. Tumor-infiltrating lymphocytes and LPMC were cultured in the presence of IL2 with/without TNF alpha (1000 U/ml each) for 5 to 8 weeks. Cytotoxicity (% lysis) was tested against Daudi target cells in a 4-hr 51Cr-release assay. The combination of IL2 and TNF alpha resulted in a significantly greater-fold expansion of TIL than IL2 alone (P less than 0.01). Lamina propria mononuclear cells expanded less than TIL, and TNF alpha had an inhibitory effect on their growth (P less than 0.05). Tumor-infiltrating lymphocytes and LPMC showed comparable cytotoxicity when cultured with IL2 alone. However, the addition of TNF alpha augmented the killer activity of TIL while inhibiting that of LPMC (P = 0.035). These results indicate that TNF alpha selectively increases the IL2-induced growth and cytotoxic function of colorectal cancer TIL, but not those of gut mucosal lymphoid cells, suggesting that TIL and LMPC differ in their response to TNF alpha. Therefore, this combination of cytokines may hold more promise than single agents for the immunotherapy of colorectal cancers with TIL.