Ileorectal bypass performed entirely through a transanal route in a porcine model.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES), a new frontier of minimally invasive surgery, uses the body's natural orifices to create an access for surgical procedures. This study aimed to verify the technical feasibility of ileorectal bypass performed entirely through a transanal access. METHODS: The procedure was performed on 10 domestic pigs, after which they were killed. A transanal endoscopic microsurgery (TEM) device and endoscopic and laparoscopic instruments were used. RESULTS: The findings demonstrated that an ileorectal bypass through a transanal access is feasible. The principal steps of a standardized transanal procedure are as follows: confirm a rectal perforation above the peritoneal reflection, perform peritoneoscopy using a standard gastroscope, grasp the small bowel with retrieval forceps and pull it through the rectal hole, suture the ileum and the rectum together using a TEM device, open the ileal loop, and perform endoscopic exploration. Satisfactory anastomosis and no signs of procedure-related complications were confirmed by a post procedure laparotomy. CONCLUSIONS: Ileorectal bypass through a transanal access is technically feasible in a porcine model, and although still at an experimental stage, it could become a surgical option for treating some types of colonic strictures.

Diode laser treatment of Barrett's esophagus: long-term results.

Different ablation techniques have been utilized in the treatment of Barrett's esophagus (BE) to reduce the risk of degeneration. Treatment complications, risk of recurrence, and buried intestinal metaplasia (IM) are all major concerns. The effect of diode laser treatment on BE, studied in a group of patients over a long-term period, is presented here. All patients with histology of IM or low-grade dysplasia (LGD) treated with diode laser therapy for BE and followed for at least 24 months were included in the study. Treatment sessions were carried out every 3 months and bioptic follow-up examinations were done yearly. Patients without antireflux surgery received proton pump inhibitors. A total of 20 patients with IM, four of them with LGD, were treated with 161 laser sessions (in mean eight per patient) without complications. Complete, sustained endoscopic and histologic remission was obtained in 13 patients (11/12 with BE ≤ 3 cm and 2/8 with BE >3 cm, p < 0.01) and a mean of 83 ± 27% of the metaplasic tissue was removed in all the patients. All four cases of LGD healed to squamous tissue. No buried metaplasia, recurrences, or disease progressions were reported after a mean follow-up of 6 years and 2 months. Diode laser ablation is a safe and effective method in most cases of short BE, while it is less effective in the long form, requiring a large number of sessions. Long-term results show that the risk of recurrence and of buried intestinal metaplasia underneath neosquamous epithelium is negligible.

Pathology of dysplasia and cancer in inflammatory bowel disease.

In both Crohn's disease and ulcerative colitis, colorectal cancer (CRC) secondary prevention basically relies on the histology detection of dysplasia. In inflammatory bowel diseases (IBD) setting, dysplasia identifies the subgroup of patients eligible to a (more) strict surveillance program (or prophylactic colectomy). In the clinical practice, a number of issues might affect the benefit of the clinico-pathological surveillance of the IBD-dysplasia-patients: sampling errors, inconsistency in biopsy assessment, patients' drop-out, etc. Even in such a multifaceted context, evidence has been provided that surveillance of dysplasia is effective in reducing both CRC mortality and morbidity. This manuscript focuses on current issues concerning the histology assessment of the IBD-associated dysplastic lesions.

Dysplasia in ulcerative colitis: still a challenge.

As duration of inflammatory bowel disease (IBD), in particular ulcerative colitis (UC), is a major risk factor for the development of colorectal cancer (CRC), it is rational to propose a screening colonoscopy when the risk starts to increase, i.e., after 8-10 years from the onset of disease. If low-grade dysplasia is detected, the 9-fold increased risk of developing CRC reported in the most recent meta-analysis could reasonably be viewed as justification for colectomy even if some follow-up studies have shown a lower rate of CRC. A reasonable compromise could be to continue surveillance with extensive biopsy sampling at shorter (perhaps 3-6 month) intervals. If high grade dysplasia is present, the decision is easier, because the risk of concomitant CRC may be as high as one third, assuming that the biopsies were indeed obtained from flat mucosa and not from an adenoma. Total proctocolectomy with ileal pouch anal anastomosis (IPAA) has become the most commonly performed procedure for patients with ulcerative colitis requiring elective surgery for dysplasia. Nevertheless, a recent systematic review alerted that the risk of dysplasia in anal transition zone and rectal cuff in patients undergone to restorative proctocolectomy was remarkable, mainly in patients operated on for dysplasia or colorectal cancer.

Colonic carcinogenesis in IBD: molecular events.

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

Deep venous thrombosis after surgery for inflammatory bowel disease: is standard dose low molecular weight heparin prophylaxis enough?

BACKGROUND: Inflammatory bowel disease (IBD) and colorectal surgery are risk factors for deep venous thrombosis (DVT). The aim of this prospective study was to evaluate the effectiveness of standardized prophylactic low molecular weight heparin (LMWH) therapy in patients who underwent surgery for ulcerative colitis (UC) and Crohn's disease (CD). PATIENTS AND METHODS: Since 1999 all patients operated on for colorectal diseases in our institute have received 4,000 IU/day LMWH from the day of operation to discharge. The complete series of patients who had major colorectal surgery from 1999 until 2006 were reviewed for overt DVT episodes. Furthermore, 60 consecutive patients who were admitted for surgery for IBD were prospectively enrolled in the 2004-2006 period. Each patient underwent venous color Doppler ultrasound scan at admission and at discharge. Demographic data, disease activity, and clotting parameters were collected. Data were analyzed with Spearman's correlation test, multiple regression, and receiver operating characteristics (ROC) curves analysis. RESULTS: The rate of DVT in UC patients was significantly higher than in colorectal cancer patients (p = 0.009), and the odds ratio (OR) for postoperative DVT in UC patients was 7.4 (95% CI 1.4-44.4; p = 0.017). Female gender, UC diagnosis, active rectal bleeding, aPTT value, aCL IgM, abeta2 IgM, and pANCA levels significantly correlated with postoperative DVT. At multivariate analysis only aCL IgM levels were found to be independently associated with postoperative DVT (p = 0.05). CONCLUSIONS: In conclusion, our study showed that prophylactic therapy with 4,000 IU/day LMWH was not completely effective for the prevention of postoperative DVT in patients with CD, and even less so in those with UC. In these patients, a more tailored prophylactic therapy should be considered, and further randomized controlled trials testing the effectiveness of different prophylactic protocols would be advisable. Furthermore, aCL IgM serum levels might be helpful in identifying IBD patients who are at higher risk of postoperative DVT.

The results of surgery for mediastinal parathyroid tumors: a comparative study of 63 patients.

PURPOSE: Parathyroidectomy for ectopic mediastinal hyperfunctioning glands could be performed by transcervical approach, sternotomy, thoracotomy, and recently by thoracoscopic and mediastinoscopic approaches. This study was aimed to analyze the results of traditional and video-assisted parathyroidectomy for mediastinal benign hyperfunctioning glands. METHODS: Fifty-one upper mediastinal exploration by a conventional cervicotomy, 12 by video-assisted approaches (two thoracoscopy and 10 transcervical mediastinoscopy) and six by sternotomy were performed in 63 patients with primary hyperparathyroidism. RESULTS: Video-assisted and sternotomic parathyroid explorations achieved biochemical cure in all cases; following conventional transcervical mediastinal exploration, a persistent hyperparathyroidism occurred in 11.8% of patients, who were subsequently cured by sternotomic approach. No complications occurred after video-assisted parathyroidectomy, while an overall morbidity rate of 50% and 10% was found after sternotomic and conventional cervicotomic approaches. Postoperative pain and hospital stay were significantly increased following sternotomy; patient's subjective cosmetic satisfaction was significantly higher after video-assisted and conventional cervicotomic approaches. CONCLUSIONS: Conventional cervicotomic parathyroidectomy may achieve satisfactory results, especially for upper mediastinal glands. Sternotomic approaches are effective, but should be limited because of invasiveness and increased morbidity. In case of deep and lower hyperfunctioning mediastinal parathyroids, video-assisted approaches represent a less invasive, effective, and safe alternative and might be the technique of choice.

Epidemiology, clinical features and diagnostic work-up of cystic neoplasms of the pancreas: Interim analysis of the prospective PANCY survey.

INTRODUCTION: A prospective survey to evaluate the diagnostic workup of cystic pancreatic neoplasms (CPNs) according to the Italian guidelines. METHODS: An online data sheet was built. RESULTS: Fifteen of the 1385 patients (1.1%) had non cystic neoplastic lesions. Forty percent (518/1295) had at least one 1st degree relative affected by a solid tumor of the digestive and extra-digestive organs. Symptoms/signs associated with the cystic lesion were present in 24.5% of the patients. The cysts were localized in the head of the pancreas in 38.5% of patients. Of the 2370 examinations (1.7 examinations per patient) which were carried out for the diagnosis, magnetic resonance imaging was performed as a single test in 48.4% of patients and in combination with endoscopic ultrasound in 27% of the cases. Of the 1370 patients having CPNs, 89.9% had an intraductal papillary mucinous neoplasm (IPMN) (70.1% a branch duct IPMN, 6.2% a mixed type IPMN and 4.6% a main duct IPMN), 12.7% had a serous cystadenoma, 2.8% a mucinous cystadenoma, 1.5% a non-functioning cystic neuroendocrine neoplasm, 0.7% a solid-pseudopapillary cystic neoplasm, 0.3% a cystic adenocarcinoma, and 1.2% an undetermined cystic neoplasm. Seventy-eight (5.7%) patients were operated upon after the initial work-up. CONCLUSIONS: This prospective study offers a reliable real-life picture of the diagnostic work-up CPN.

The hostile neck does not increase the risk of carotid endarterectomy.

INTRODUCTION: Hostile neck anatomy is assumed to be associated with increased surgical risk for patients undergoing carotid endarterectomy (CEA) and is often considered a reason to choose carotid stenting or medical management. This retrospective case-control study evaluated whether, and how much, anatomically hostile necks represent a condition of higher surgical risk of early and late mortality and major or minor morbidity. METHODS: The data for 966 homogeneous CEA patients was prospectively entered in a computer database. Seventy-seven had a hostile neck anatomy due to previous oncologic surgery or neck irradiation, restenoses after CEA, high carotid bifurcation, or bull-like and inextensible neck. A case-control matched-pair cohort study considered sex, age (5-year intervals), and year of operation. Regional anesthesia was used for all operations for atherosclerotic stenosis >or=70%, conforming to the European Carotid Surgery Trial (ECST) in symptomatic and asymptomatic patients, at a single center and by one surgeon or under his direct supervision. RESULTS: The hostile neck patients and the control group were matched for age, sex, carotid-related symptoms, degree of stenoses, and main risk factors for cardiovascular diseases. Intraoperative variables were substantially equivalent in the two groups; however, procedure length and clamping time were, respectively, about 22 minutes (P = .0001) and 7 minutes longer (P = .01) in the hostile neck group. Rates of postoperative mortality and neurologic events were equivalent. Peripheral nerve lesions were multiple and significantly more frequent in the hostile neck patients (21% with >or=1 cranial nerve lesion vs 7% of controls, P = .03), yet all were transient and limited to a few months. The subgroups of patients with hostile neck, restenoses, and bull-like inextensible necks required the longest operative and clamping time, and those with bull-like and high bifurcation had the most frequent cranial nerve dysfunctions. At the respective follow-up of 47 and 45 months, survival curves (P = .48) and the incidence of restenoses and fatal and nonfatal strokes were similar (5 and 4, respectively). CONCLUSIONS: Hostile necks led to more complex CEA procedures but without substantial consequences in early and late morbidity and mortality. Most patients with hostile neck can undergo CEA at low risk, with the benefit of effective long-lasting stroke prevention similar to standard patients. In our opinion, the more frequent but temporary cranial nerve dysfunctions that occur are not sufficient to consider hostile neck patients noneligible for CEA.

Endovascular treatment of acute pseudoaneurysm associated to pancreaticoduodenectomy.

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

Retrospective multicenter study of post-operative stenosis after stapled colorectal anastomosis.

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

The usefulness of preoperative ultrasonographic identification of nonrecurrent inferior laryngeal nerve in neck surgery.

BACKGROUNDS AND AIMS: Nonrecurrent inferior laryngeal nerve (ILN) represents a risk factor for injury during neck surgery. It is associated to arterial abnormalities (absence of the brachiocephalic trunk and arteria lusoria) that can be identified by ultrasonography. The aim of the study was to verify the usefulness of preoperative ultrasonography in the research of nonrecurrent ILN by the means of identification of arterial abnormalities and the impact on ILN morbidity. PATIENTS AND METHODS: The study included 750 patients who underwent neck surgery with right-side ILN dissection. A preoperative ultrasonography aimed to identify arterial abnormalities associated to nonrecurrent ILN was performed in 400 patients (Group A) while no preoperative attempts were performed in the remaining patients (Group B). Patients' characteristics, time for intraoperative identification of the ILN, and morbidity were compared. RESULTS: Five and four nonrecurrent ILN were identified in groups A and B, respectively (p = NS). Preoperative ultrasonography correctly predicted nonrecurrent ILN in all cases (accuracy 100%). Nonrecurrent ILN palsy never occurred in group A, while three cases occurred in group B (p < 0.05). The mean time for intraoperative identification of both nonrecurrent and normally recurrent ILN was significantly shorter in group A (p < 0.01). CONCLUSIONS: Preoperative ultrasonography can correctly identify nonrecurrent ILN, allowing earlier nerve identification and prevention of injuries.

Different apoprotein(a) isoform proportions in serum and carotid plaque.

INTRODUCTION: Cardio- and/or cerebro-vascular risk are associated with high lipoprotein (a) [Lp(a)] levels and low-molecular-weight (LMW) apo(a) isoforms. Aims of this study were to evaluate the deposition of apo(a) isoforms and apoprotein B (apo B) in atherosclerotic plaque from patients (males and females) who had carotid endarterectomy for severe stenosis, and to identify differences between patients classified by gender and divided according to the stability or instability of their plaques. MATERIALS AND METHODS: We determined lipids, apo B and Lp(a) in serum and plaque extracts from 55 males and 25 females. Apo(a) was phenotyped and isoforms were classified by number of kringle IV (KIV) repeats. RESULTS: Lp(a) levels were higher in female serum and plaque extracts than in male samples, while apo B levels were lower. More Lp(a) than apo B deposition was observed in plaque after normalization for serum levels. Thirty-one different apo(a) isoforms were detected in our patients, with a double band phenotype in 94% of cases. In both sexes, the low/high (L/H) molecular weight apo(a) isoform expression ratio was significantly higher in plaque than in serum. Females with unstable plaques had higher Lp(a) levels in both serum and tissue extracts, and fewer KIV repeats of the principal apo(a) isoform in the serum than the other female group or males. CONCLUSIONS: In both sexes, the same apo(a) isoforms are found in serum and atherosclerotic plaque, but in different proportions: in plaque, LMW apo(a) is almost always more strongly accumulated than HMW apo(a), irrespective of any combination of apo(a) isoforms in double band phenotypes or Lp(a) serum levels. Moreover, serum and tissue Lp(a) levels were higher in females than in males, and particularly in the group with unstable plaques.

Health-related quality of life after ileocolonic resection for Crohn's disease: long-term results.

BACKGROUND: Crohn's disease (CD) is a chronic illness that interferes with the daily life of those affected. The aim of the present study was to evaluate long-term health-related quality of life (HRQL) outcome and its clinical predictors in CD patients who have had ileocolonic resection. METHODS: Ninety-seven CD patients, with a mean follow-up of 47.1 months (95% CI, 40.7-53.5 months) after ileocolonic resection, were interviewed by telephone and responded to the generic Cleveland Global Quality of Life (CGQL) questionnaire, and 63 of them also agreed to come to our outpatient clinic to have a Crohn's Disease Activity Index (CDAI) assessment and blood test and to answer the disease-specific Padova Inflammatory Bowel Diseases Quality of Life (PIBDQL) questionnaire. Control groups also were enrolled. RESULTS: The CGQL scores of the 97 CD patients were similar to those of 69 healthy controls. Only the item on current quality of health was scored significantly lower by patients with CD. In contrast, the PIBDQL item and total scores of the CD patients were all significantly lower than those of the respective healthy controls (P < 0.05). Multivariate analysis showed that the CGQL and PIBDQL scores both had a strong linear relationship with number of daily stools and with CDAI score (P < 0.05). CONCLUSIONS: Despite CD patients who have undergone ileocolonic resection having an apparently normal quality of life with a good energy level, as shown by the CGQL, their long-term HRQL is still affected by a significantly impaired quality of health. In fact, the PIBDQL questionnaire showed significant impairment of bowel and systemic symptom domains with important consequences for emotional and social functions. HRQL seems to be significantly related only to current disease activity.

Cytokine network in chronic perianal Crohn's disease and indeterminate colitis after colectomy.

Antitumor necrosis factor alpha (anti-TNF-alpha) therapy in perianal Crohn's disease (CD) is widely established but recent studies suggest that the underlying fistula tract and inflammation may persist. Treatment with a monoclonal antibody against interleukin (IL)-12 was reported to induce clinical responses and remissions in patients with active CD. The aim of our study was to analyze the cytokine network (TNF-alpha, IL-12, IL-1beta, and IL-6) in 12 patients with chronic perianal CD and a Crohn's disease activity index (CDAI) score <150 to exclude active intestinal disease, in 7 patients with indeterminate colitis (IC) after restorative proctocolectomy with perianal complications, in 7 patients with active intestinal CD without perianal manifestations, and in 19 healthy controls. Nonparametric Mann-Whitney U test and Spearman's rank correlation test were used. Serum TNF-alpha levels were significantly higher in patients with IC than perianal CD patients and healthy controls. Serum TNF-alpha levels significantly correlated with perianal CDAI score and with the presence of anal fistulas. Serum IL-12 levels correlated with the presence of anal strictures and were similar in all groups. Serum IL-6 levels were significantly higher in the presence of perianal fistulas and lower in the presence of anal strictures. Our study confirmed that TNF-alpha plays a major role in the perianal and intestinal CD. Furthermore, the significantly higher TNF-alpha serum levels in patients with IC suggest the use of anti-TNF-alpha in such patients. On the contrary, according to our results the efficacy of anti-IL-12 antibodies appears doubtful in chronic perianal CD or IC without anal strictures. The role of IL-6 as a systemic mediator for active chronic inflammation was confirmed and a possible role for its monoclonal antibody was suggested.

Risk factors of endoleak following endovascular repair of abdominal aortic aneurysm. A multicentric retrospective study.

Endoleak (EL) represents the most common complication following endovascular abdominal aortic aneurysm repair (EVAR). Unfortunately, the long-term results of EVAR and its durability have been questioned, and EL are variably associated with a risk of late failure. The aim of this retrospective study was to identify risk factors for this complication of aneurysm-endograft complex in patients who underwent EVAR. A group of 104 consecutive patients (99 men, 5 women; median age, 74 years; range, 50-89 years) were enrolled in the study. Both preoperative and follow-up imaging studies were obtained using helical computed tomography scanning at 1, 6, 12, 24, 36 months after EVAR and blindly reviewed by a surgeon and a radiologist. Twenty-seven (25.9%) patients developed EL during follow-up, of which 10 (37%) were primary (<30 days from EVAR), and 17 (63%) were secondary EL. Age and smoking did not affect the EL onset, while a body mass index >25 and a history or presence of arterial hypertension represented significant (p<0.05) risk factors. Moreover, both greatest diameter and maximum length of the aneurysm were significantly higher (p<0.01) in patients who developed EL. No relationship was found with the anatomical features of the aortic neck (i.e. length and diameter), and between the initial size of the aneurysm and the dimension at the time of EL. In conclusion, in our study, being overweight, arterial hypertension and the initial size of the aneurysm represent risk factors for EL development.

Endoscopic dilation of benign esophageal strictures in a surgical unit: a report on 95 cases.

Ninety-five patients were treated by endoscopic dilation without fluoroscopic guidance between 1997 and 2005 for benign esophageal strictures. The etiologies were: anastomotic (38), postfundoplication (13), caustic (14), peptic (11), radiation-induced (10) and others (9). The strictures were classified at every session on a 0 to 4 scale on the basis of the diet and the luminal diameter. Savary-Gillard or Through-the Scope balloon dilators were used depending on the type and the location of the stenosis. A total of 472 dilation sessions were carried out without serious complications. A normal and a semisolid diet were respectively achieved in 75% and 91%. Recurrence of dysphagia was found in 33% and 51% of the patients respectively after 2 months and 1 year. Improvement of dysphagia, the number of sessions, and recurrence were significantly better in the patients with postsurgical stenosis as compared with those affected by caustic, peptic, and radiation-induced strictures.

Peritoneal mesothelioma: a review.

BACKGROUND: Malignant peritoneal mesothelioma (MPM) is a rare aggressive tumor of the peritoneum, regarded as a universally fatal disease. It is poorly described and the knowledge of its natural history is very limited. Occupational and environmental asbestos exposure still remains a public health problem around the world. The incidence has increased in the past 2 decades. Only 20% to 33% of all mesotheliomas arise from the peritoneum itself; the pleura is the most common site of origin.

[Ruptured aneurysms of the abdominal aorta: from the First Aid to the Operating Room. Changing concepts]. / Aneurismi dell'aorta addominale in rottura: dal Pronto Soccorso alla sala operatoria Moderni orientamenti.

Worldwide literature review from PubMed indicate that progress has been made in first aid assistance, diagnosis and treatment of ruptured abdominal aortic aneurysms, which led to a reduced operative mortality. Nevertheless, ruptured aneurysms may present atipically in about half of the cases, thus leading to an initially uncorrect diagnosis up to 25% of cases. Mean survival interval from onset of symptoms and death is 10-14 hours, thus indicating that time exists to consider the new imaging techniques in 80% of patients, particularly the TC multislice. This, when is strategically located close to the emergency or the operative room, can rapidly allow a correct diagnosis and provide an accurate morphological evaluation, thus enabling the surgeon to plan the most adequate treatment with open or endovascular repair.

5-fluorouracil and weekly oxaliplatin combined with radiotherapy for locally advanced rectal cancer: surgical complications and long-term results.

BACKGROUND: We undertook this study to evaluate early surgical complications and long-term results after preoperative radiotherapy and chemotherapy (RCT) using 5-fluorouracil (5-FU) and oxaliplatin (OXA) for rectal cancer. METHODS: Forty six TNM stage II-III rectal cancer patients were studied, who were given preoperative RT (50.4 Gy/28 fractions) combined with 5-FU (200-225 mg/m(2)/day by continuous venous infusion) and weekly OXA (25-60 mg/m(2)). Major complications and reoperations were recorded overall, whereas outcome analyses were performed only for patients who received the recommended regimen dosage. RESULTS: Forty three patients (M:F, 25:18; median age 59 years) were available for analysis. All patients received the planned RT dose. There were no postoperative deaths; seven patients had early major surgical complications, four requiring re-operation. One additional patient had a second surgical procedure due to a duodenal fistula complicating the resection of an aortic aneurysm performed concomitantly with rectal cancer surgery. At a median follow-up of 49 months, two of the 23 patients treated at the recommended doses developed recurrence (one local, and one local and distant), and two died of cancer progression. Following the Kaplan-Meier method, the estimated 5-year overall and disease-free survival rates were 92 and 89%, respectively. CONCLUSIONS: The preoperative RCT regimen used in the present study incurs a low rate of recurrence with an acceptable surgical morbidity.