Unique osteogenic profile of bone marrow stem cells stimulated in perfusion bioreactor is Rho-ROCK-mediated contractility dependent.

The fate determination of bone marrow mesenchymal stem/stromal cells (BMSC) is tightly regulated by mechanical cues, including fluid shear stress. Knowledge of mechanobiology in 2D culture has allowed researchers in bone tissue engineering to develop 3D dynamic culture systems with the potential for clinical translation in which the fate and growth of BMSC are mechanically controlled. However, due to the complexity of 3D dynamic cell culture compared to the 2D counterpart, the mechanisms of cell regulation in the dynamic environment remain relatively undescribed. In the present study, we analyzed the cytoskeletal modulation and osteogenic profiles of BMSC under fluid stimuli in a 3D culture condition using a perfusion bioreactor. BMSC subjected to fluid shear stress (mean 1.56 mPa) showed increased actomyosin contractility, accompanied by the upregulation of mechanoreceptors, focal adhesions, and Rho GTPase-mediated signaling molecules. Osteogenic gene expression profiling revealed that fluid shear stress promoted the expression of osteogenic markers differently from chemically induced osteogenesis. Osteogenic marker mRNA expression, type 1 collagen formation, ALP activity, and mineralization were promoted in the dynamic condition, even in the absence of chemical supplementation. The inhibition of cell contractility under flow by Rhosin chloride, Y27632, MLCK inhibitor peptide-18, or Blebbistatin revealed that actomyosin contractility was required for maintaining the proliferative status and mechanically induced osteogenic differentiation in the dynamic culture. The study highlights the cytoskeletal response and unique osteogenic profile of BMSC in this type of dynamic cell culture, stepping toward the clinical translation of mechanically stimulated BMCS for bone regeneration.

Electronic Health Records at People's Hands Across Europe: The InteropEHRate Protocols.

Sharing of personal health data could facilitate and enhance the quality of care and the conduction of further research studies. However, these data are still underutilized due to legal, technical, and interoperability challenges, whereas the data subjects are not able to manage, interact, and decide on what to share, with whom, and for what purposes. This barrier obstacles continuity of care across in the European Union (EU), and neither healthcare providers nor data researchers nor the citizens are benefiting through efficient healthcare treatment and research. Despite several national-level EU studies and research activities, cross-border health data exchange and sharing is still a challenging task, which is addressed only under specific cases and scenarios. This manuscript presents the InteropEHRate research project along with its key innovations, aiming to offer Electronic Health Records (EHRs) at peoples' hands across the EU, via the exploitation of three (3) different protocol families, namely the Device-to-Device (D2D), Remote-to-Device (R2D), and Research Data Sharing (RDS) protocols. These protocols facilitate efficient, secure, privacy preserving, and General Data Protection Regulation (GDPR) compliant health data sharing across the EU, covering different real-world use cases.

Introducing the CYSAS-S3 Dataset for Operationalizing a Mission-Oriented Cyber Situational Awareness.

The digital transformation of the defence sector is not exempt from innovative requirements and challenges, with the lack of availability of reliable, unbiased and consistent data for training automatisms (machine learning algorithms, decision-making, what-if recreation of operational conditions, support the human understanding of the hybrid operational picture, personnel training/education, etc.) being one of the most relevant gaps. In the context of cyber defence, the state-of-the-art provides a plethora of data network collections that tend to lack presenting the information of all communication layers (physical to application). They are synthetically generated in scenarios far from the singularities of cyber defence operations. None of these data network collections took into consideration usage profiles and specific environments directly related to acquiring a cyber situational awareness, typically missing the relationship between incidents registered at the hardware/software level and their impact on the military mission assets and objectives, which consequently bypasses the entire chain of dependencies between strategic, operational, tactical and technical domains. In order to contribute to the mitigation of these gaps, this paper introduces CYSAS-S3, a novel dataset designed and created as a result of a joint research action that explores the principal needs for datasets by cyber defence centres, resulting in the generation of a collection of samples that correlate the impact of selected Advanced Persistent Threats (APT) with each phase of their cyber kill chain, regarding mission-level operations and goals.

Data Sources and Gateways: Design and Open Specification.

INTRODUCTION: With With the proliferation of available ICT services, several sensors and health applications have become ubiquitous, while many applications have been developed to detect certain health conditions and early signs of disease. Currently, all these services operate independently, and the available data is heterogeneous with limited value gained from its exploitation. AIM: The Data Sources and Gateways component aims at providing an abstracted and unified API to support the data accumulation from various sources including healthcare organisations, biosensors, laboratories and mobile applications. Meanwhile it tackles connectivity and communication issues with such information sources. METHODS: The CrowdHEALTH Data Sources and Gateways Service incorporates four main services: The Configuration Service, The DB Connection Handling Service, The File Parsing Service and The RESTful Client Service. RESULTS: The initial version of the component design has built upon the requirements collected from the use case participants acting also as data providers. CONCLUSION: These four services presented in this paper guide the implementation of the first version of the Data Sources and Gateways component software prototype. The Data Sources and Gateways component remains to be evaluated within the context of the project and be enriched in order to meet additional end user needs.

The CrowdHEALTH project and the Hollistic Health Records: Collective Wisdom Driving Public Health Policies.

INTRODUCTION: With the expansion of available Information and Communication Technology (ICT) services, a plethora of data sources provide structured and unstructured data used to detect certain health conditions or indicators of disease. Data is spread across various settings, stored and managed in different systems. Due to the lack of technology interoperability and the large amounts of health-related data, data exploitation has not reached its full potential yet. AIM: The aim of the CrowdHEALTH approach, is to introduce a new paradigm of Holistic Health Records (HHRs) that include all health determinants defining health status by using big data management mechanisms. METHODS: HHRs are transformed into HHRs clusters capturing the clinical, social and human context with the aim to benefit from the collective knowledge. The presented approach integrates big data technologies, providing Data as a Service (DaaS) to healthcare professionals and policy makers towards a "health in all policies" approach. A toolkit, on top of the DaaS, providing mechanisms for causal and risk analysis, and for the compilation of predictions is developed. RESULTS: CrowdHEALTH platform is based on three main pillars: Data & structures, Health analytics, and Policies. CONCLUSIONS: A holistic approach for capturing all health determinants in the proposed HHRs, while creating clusters of them to exploit collective knowledge with the aim of the provision of insight for different population segments according to different factors (e.g. location, occupation, medication status, emerging risks, etc) was presented. The aforementioned approach is under evaluation through different scenarios with heterogeneous data from multiple sources.

Characteristics and outcomes of laparoscopic surgery in patients with large hiatal hernia. A single center study.

INTRODUCTION: Giant hiatal hernia is characterized by the presence of more than 1/3 of the stomach in the chest, through the diaphragmatic hiatus, with or without other intra-abdominal organs. It is a rare pathology, representing the 5-10% of all hiatal hernias. The advent of laparoscopic surgery led to new surgical techniques, which include the simple reduction with the excision of the hernial sac and the execution of a posterior hiatoplasty, with or without mesh, and the execution of a Collis-Nissen gatroplasty in case of short esophagus. PRESENTATION OF CASES: We followed 24 cases of giant hiatal hernia with more than 1/3 stomach located in the chest, analyzing the results reached by the miniinvasive procedure, and the long-term pathophysiologic results of the disease. DISCUSSION: Laparoscopic hiatal hernia repair results in less postoperative pain compared with the open approach. The smaller incisions of minimally-invasive surgery are less likely to be complicated by incisional hernias and wound infection. Postoperative respiratory complications are reduced. CONCLUSION: Results from multiple studies are similar, with shorter hospital stay and less morbidity resulting from the minimally invasive approach.

CrowdHEALTH: Holistic Health Records and Big Data Analytics for Health Policy Making and Personalized Health.

Today's rich digital information environment is characterized by the multitude of data sources providing information that has not yet reached its full potential in eHealth. The aim of the presented approach, namely CrowdHEALTH, is to introduce a new paradigm of Holistic Health Records (HHRs) that include all health determinants. HHRs are transformed into HHRs clusters capturing the clinical, social and human context of population segments and as a result collective knowledge for different factors. The proposed approach also seamlessly integrates big data technologies across the complete data path, providing of Data as a Service (DaaS) to the health ecosystem stakeholders, as well as to policy makers towards a "health in all policies" approach. Cross-domain co-creation of policies is feasible through a rich toolkit, being provided on top of the DaaS, incorporating mechanisms for causal and risk analysis, and for the compilation of predictions.

Applicability of the Proposed Japanese Model for the Classification of Gastric Cancer Location: The "PROTRADIST" Retrospective Study.

BACKGROUND: The extension of lymphadenectomy for surgical treatment of gastric cancer remains discordant among European and Japanese surgeons. Kinami et al. (Kinami S, Fujimura T, Ojima E, et al. PTD classification: proposal for a new classification of gastric cancer location based on physiological lymphatic flow. Int. J. Clin. Oncol. 2008;13:320-329) proposed a new experimental classification, the "Proximal zone, Transitional zone, Distal zone" (PTD) classification, based on the physiological lymphatic flow of gastric cancer site. The aim of the present retrospective study is to assess the applicability of PTD Japanese model in gastric cancer patients of our Western surgical department. METHODS: Two groups of patients with histologically documented adenocarcinoma of the stomach were retrospectively obtained: In the first group were categorized 89 patients with T1a-T1b tumor invasion; and in the second group were 157 patients with T2-T3 category. The data collected were then categorized according to the PTD classification. RESULTS: In the T1a-T1b group there were no lymph node metastases within the r-GA or r-GEA compartments for tumors located in the P portion, and similarly there were no lymphatic metastases within the l-GEA or p-GA compartments for tumors located in the D portion. On the contrary, in the T2-T3 group the lymph node metastases presented a diffused spreading with no statistical significance between the two classification models. CONCLUSIONS: Our results show that the PTD classification based on physiological lymphatic flow of the gastric cancer site is a more physiological and clinical version than the Upper, Medium And Lower classification. It represents a valuable and applicable model of cancer location that could be a guide to a tailored surgical approach in Italian patients with neoplasm confined to submucosa. Nevertheless, in order to confirm our findings, larger and prospective studies are needed.

An unusual case of left hepatectomy for Focal Nodular Hyperplasia (FNH) linked to the use of Anabolic Androgenic Steroids (AASs).

INTRODUCTION: Focal Nodular Hyperplasia (FNH) is the second most common benign tumor of the liver. Clinically FNH is asymptomatic and discovered incidentally . The pathogenesis is unclear; FNH is usually asymptomatic. When the tumor is large, it may be painful. Surgery is recommended only in the case of complications such as compression of adjacent organs, lesion progression with tumor size >5cm and presence of symptoms. PRESENTATION OF CASE: A 30 years old man, was evaluated during a routine visit, for diffuse abdominal pain and weight loss; Abdominal ultrasound showed no evidence of biliary obstruction but the US shows a hypoechoic, well defined focal lesion in the left liver. For a more accurate diagnosis a Magnetic Resonance detected a focal area about 14×9 cm in diameter, hypointense. Liver biopsy was not done.We could not diagnose it definitively as FNH from the results of imaging studies; so for the size of symptomatic lesion, the undefined diagnosis of FNH ,and due to the great increase in the size of the mass located in the left lobe, during such a short period , the surgery was been recommended. DISCUSSION: FNH is the second most common hepatic lesion, but clinically relevant cases of FNH are rare with a reported prevalence in US studies of 0,03%. In our case the young patient was taking dietary supplements including anabolic androgenic steroids (AASs), carnitine and l-arginine. CONCLUSION: The particularity of our case is the increasing of the lesion in two years in which the patient made use of anabolic steroids. under use of . This could be the explanation for increasing of nodule.

A rare case of Wunderlich syndrome five days after left hemicolectomy for colorectal cancer.

INTRODUCTION: Wunderlich syndrome (WS) is a surgical emergency characterized by spontaneous, non-traumatic retroperitoneal hemorrhage. Angiomyolipoma (AML), a benign mesenchymal tumor, is the most frequent cause of WS. We present a case of WS, appearance five days after a left hemicolectomy for cancer. PRESENTATION OF CASE: A 66 years-old man with a sigmoid adenocarcinoma and a small left AML (3.4cm) was undergone to left hemicolectomy. He was subjected to bridging therapy with high doses of low-molecular-weight heparin for prosthetic replacement of heart valve secondary to endocarditis and atrial fibrillation. Five days after surgery he presents retroperitoneal hemorrhage due to rupture of AML diagnosed by a CT scan and scintigraphy with labeled red blood cells. Total left nephrectomy was performed as the patient became unstable. DISCUSSION: Rupture of a renal AML is the main cause of WS. This risk increases with the size of the tumor (>4cm) and during pregnancy. CT scan is the best imaging modalities for diagnosis. The bridging therapy increases the perioperative bleeding risk. These patients are conservative treated with selective transarterial embolization. Nephrectomy is limited for the patients hemodynamically unstable or in case of failed embolization. CONCLUSION: This is a unusual case of WS after surgery in patients with small AML and treated with high dose of anticoagulant for cardiac disease. There are no other similar cases in literature.

Sarcomatoid Carcinoma of the lung: A rare case of three small intestinal intussusceptions and literature review.

INTRODUCTION: Sarcomatoid carcinoma is an extremely rare, biphasic tumor characterized by a combination of malignant epithelial and mesenchymal cells. Limited data showed that most cases occurred with advanced local disease and metastasis. PRESENTATION OF CASE: We present a rare case of a 60-year-old man with three small intestinal intussusceptions due to metastatic pulmonary carcinosarcoma. He was explored for chest pain and hemoptysis in Emergency room. Due to his chest symptoms he had a computed tomography (CT) scan of the chest which showed a lesion about 60mm in diameter in the inferior lobe of the left lung. After 2 weeks physical examination demonstrated a distended abdomen and auscultation was indicated by hyperactive bowel sounds. Further imaging studies with abdominal computed tomography (CT) scan, showed multiple protruding small bowel tumors with entero enteric intussusceptions at three sites requiring a massive bowel resection at surgery. The pathology showed that it was positive for cytokeratin, vimentin, CD-34, and LIS; CK7 was focally positive; and CD117, CD20, and desmine were negative. The final diagnosis was metastatic small bowel carcinosarcoma with a lung primary. DISCUSSION: Lung carcinosarcoma is a high grade biphase neoplasm. The survival rate at 6 months is only around 27%. CONCLUSION: There are rare reports of small intestinal intussusceptions caused by metastatic lung carcinosarcoma, this presentation shows the third case in literature. Physicians should be more alert to symptoms or signs indicating GI metastais in patients with a history of lung cancer.

Large symptomatic gastric diverticula: two case reports and a brief review of literature.

Gastric diverticula are rare and uncommon conditions. Most gastric diverticula are asymptomatic. When symptoms arise, they are most commonly upper abdominal pain, nausea and emesis, while dyspepsia and vomiting are less common. Occasionally, patients with gastric diverticula can have dramatic presentations related to massive bleeding or perforation. The diagnosis may be difficult, as symptoms can be caused by more common gastrointestinal pathologies and only aggravated by diverticula. The appropriate management of diverticula depends mainly on the symptom pattern and as well as diverticulum size. There is no specific therapeutic strategy for an asymptomatic diverticulum. Although some authors support conservative therapy with antacids, this provides only temporary symptom relief since it is not able to resolve the underlying pathology. Surgical resection is the mainstay of treatment when the diverticulum is large, symptomatic or complicated by bleeding, perforation or malignancy, with over two-thirds of patients remaining symptom-free after surgery, while laparoscopic resection, combined with intraoperative endoscopy, is a safe and feasible approach with excellent outcomes. Here, we present two cases of uncommon large symptomatic gastric diverticula with a discussion of the cornerstones in management and report a minimally invasive solution, with a brief review of the literature.

The calibrated laparoscopic Heller myotomy with fundoplication.

BACKGROUND: Esophageal achalasia is the most common primary esophageal motor disorder. Laparoscopic Heller's myotomy combined with fundoplication represents the treatment of choice for this disease, achieving good results in about 90% of patients. However, about 10% of treated patients refer persistent or recurrent dysphagia. Many Authors showed that this failure rate is related to inadequate myotomy. OBJECTIVE: To verify, from experimental to clinical study, the modifications induced by Heller's myotomy of the esophago- gastric junction on LES pressure (LES-P profile, using a computerized manometric system. METHODS: From 2002 to 2010 105 patients with achalasia underwent laparoscopic calibrated Heller myotomy followed by antireflux surgery. The calibrated Heller myotomy was extended for at least 2.5 cm on the esophagus and for 3 cm on the gastric side. Each step was evaluated by intraoperative manometry. Moreover, intraoperative manometry and endoscopy were used to calibrate the fundoplication. RESULTS: The preoperative mean LES-P was 37.73 ± 12.21. After esophageal and gastric myotomy the mean pressure drop was 21.3% and 91.9%, respectively. No mortality was reported. CONCLUSION: Laparoscopic calibrated Heller myotomy with fundoplication achieves a good outcome in the surgical treatment of achalasia. The use of intraoperative manometry enables an adequate calibration of myotomy, being effective in the evaluation of the complete pressure drop, avoiding too long esophageal myotomy and, especially, too short gastric myotomy, that may be the cause of surgical failure.

Laparoscopic Nissen-Rossetti fundoplication is a safe and effective treatment for both Acid and bile gastroesophageal reflux in patients poorly responsive to proton pump inhibitor.

PURPOSE: The aim of this study was to evaluate the effectiveness of laparoscopic Nissen-Rossetti fundoplication in patients with gastroesophageal reflux disease (GERD) poorly responsive to standard dose proton pump inhibitor (PPI) therapy. METHODS: A total of 35 patients (19 women, 16 men, mean age 44.6 ± 14.01 years) were enrolled. All the patients underwent symptom questionnaires, upper gastrointestinal endoscopy, esophageal manometry, and combined 24-hour esophageal pH and bilirubin monitoring. Following this, the patients with persistent pathological esophageal acid and/or bilirubin exposure underwent laparoscopic antireflux surgery, followed by clinical and instrumental 12-month follow-up. RESULTS: One year after surgery, there was a significant improvement of symptom score, compared with standard PPI dose period (3.54 ± 1.67 vs 20.8 ± 10.9, P < .0001; paired t test) and mean percentage total time acid and bile exposure showed a significant decrease (4.9 ± 2.9 vs 2.03 ± 0.74 and 8.3 ± 3.03 vs 0.84 ± 0.56, P < .0001; paired t test). CONCLUSIONS: In patients with GERD poorly responsive to standard PPI dose, laparoscopic Nissen-Rossetti fundoplication appears to be a safe and effective treatment of symptoms, esophageal damage, as well as both acid and bile reflux.

Report of a rare case of colon cancer complicated by anomalies of intestinal rotation and fixation: a case report.

INTRODUCTION: The Situs viscerum inversus associated with anomalies of intestinal rotation and fixation is an extremely rare condition. To the authors' knowledge, this is the first report of colon cancer associated with intestinal malrotation and mesenterium ileocolicum commune. CASE PRESENTATION: A 34-year-old man with a 2-month history of diarrhea associated with abdominal pain and weight loss underwent abdominal ultrasonography, colonscopy with biopsies and abdominal computed tomography scan with intravenous contrast. A right colonic neoplasm was diagnosed, observed only at surgery, as neither computed tomography or ultrasonography showed the intestinal malrotation. Particularly, the third and the fourth part of the duodenum descended vertically, without Treitz's ligament in support to the duodeno-jejunal flexure. The small bowel and the colon were located in the right and left side of the abdominal cavity, respectively. CONCLUSION: The anomaly of situs viscerum inversus influenced the surgical strategy in this case because of the vascular and lymphatic anomalies. Lymphatic vessels were therefore marked with subserosal injection of patent blue in the proximity of the tumor. Subsequently, right colectomy was performed. Colectomy extended from the distal ileum to the descending colon, by ligature of the right colic artery and vein at the origin from the superior mesenteric vessels. Patent blue guided lymphadenectomy was also performed with curative intent. Finally, a mechanical ileo-colic anastomosis was carried out. After right colectomy and ileo-descending anastomosis, the Ladd's procedure for intestinal malrotation was unnecessary. The authors believe that this strategy, despite the anatomical difficulties, represents an effective procedure for the radical surgical treatment of the right colon cancer associated with anomalies of intestinal rotation and fixation.

Prevalence of bile reflux in gastroesophageal reflux disease patients not responsive to proton pump inhibitors.

AIM: To determine the prevalence and characteristics of bile reflux in gastroesophageal reflux disease (GERD) patients with persistent symptoms who are non-responsive to medical therapy. METHODS: Sixty-five patients (40 male, 25 female; mean age, 50 +/- 7.8 years) who continued to report symptoms after 8 wk of high-dose proton pump inhibitor (PPI) therapy, as well as 18 patients with Barrett's esophagus, were studied. All patients filled out symptom questionnaires and underwent endoscopy, manometry and combined pH-metry and bilimetry. RESULTS: There were 4 groups of patients: 22 (26.5%) without esophagitis, 24 (28.9%) grade A-B esophagitis, 19 (22.8%) grade C-D and 18 (21.6%) Barrett's esophagus. Heartburn was present in 71 patients (85.5%) and regurgitation in 55 (66.2%), with 44 (53%) reporting simultaneous heartburn and regurgitation. The prevalence of pathologic acid reflux in the groups without esophagitis and with grades A-B and C-D esophagitis was 45.4%, 66.6% and 73.6%, respectively. The prevalence of pathologic bilirubin exposure in these 3 groups was 53.3%, 75% and 78.9%, respectively. The overall prevalence of bile reflux in non-responsive patients was 68.7%. Pathologic acid and bile reflux was observed in 22.7% and 58.1% of non-esophagitic patients and esophagitic patients, respectively. CONCLUSION: The high percentage of patients poorly responsive to PPI therapy may result from poor control of duodenogastroesophageal reflux. Many patients without esophagitis have simultaneous acid and bile reflux, which increases with increasing esophagitis grade.

Prevalence of pathological duodenogastric reflux and the relationship between duodenogastric and duodenogastrooesophageal reflux in chronic gastrooesophageal reflux disease.

UNLABELLED: The role of duodenogastric reflux in gastrooesophageal reflux disease is still controversial. AIMS: (i) To determine the prevalence of pathological duodenogastric reflux (DGR) in gastrooesophageal reflux disease patients and (ii) to define the relationship between DGR and duodenogastrooesophageal reflux. METHODS: We evaluated 92 patients referred for investigation of recurrent reflux symptoms after proton pump inhibitors (PPI) therapy. All the patients filled out symptom questionnaires and underwent endoscopy, oesophageal manometry and combined oesophagogastric pH and bilirubin monitoring. RESULTS: Endoscopy divided the 92 patients into four groups (group I: 25 nonoesophagitis patients, group II: 26 patients with grade A-B oesophagitis, group III: 21 patients with grade C-D oesophagitis and group IV: 20 patients with Barrett's oesophagus. Twenty-four of the 92 patients (26%) showed pathological DGR. Abnormal oesophageal bilirubin exposure was observed in 62 of the 92 patients (67.4%). Of the 62 patients with abnormal oesophageal bilimetry, 15 (24.2%) patients simultaneously showed pathological DGR. The gastric bilirubin exposure in patients with abnormal oesophageal, Bilitec tests did not differ from that in patients with normal oesophageal bilimetry (P>0.05). A weak correlation between oesophageal and gastric bilirubin exposure, both expressed as a percentage of time, was found (r=0.28; P<0.01). CONCLUSION: Pathological DGR is present in a little more than a quarter of patients with recurrent reflux and dyspeptic symptoms after PPI therapy. Excessive DGR is not a prerequisite for pathological oesophageal exposure to duodenal contents. Gastric bilirubin monitoring may be useful to choose the best surgical treatment for patients with reflux and dyspeptic symptoms refractory to PPI.

Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial.

PURPOSE: This prospective, randomized, controlled trial was designed to compare the clinical, functional, and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure. METHODS: All patients with symptomatic chronic anal fissure were randomly assigned to pneumatic balloon dilatation or lateral internal sphincterotomy and invited to complete a standardized questionnaire inquiring about their symptoms. Anal ultrasonography and anal manometry were performed before and six months after surgery. A proctologic examination was performed between the fifth and sixth postoperative weeks. Anal continence, scored by using a validated continence grading scale, was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months. RESULTS: Fifty-three patients, who satisfied selection criteria, were enrolled in the trial. Four patients (7.5 percent) were lost to follow-up. Twenty-four patients (11 males; mean age, 42 +/- 8.2 years) underwent pneumatic balloon dilatation and 25 patients (10 males; mean age, 44 +/- 7.3 years) underwent lateral internal sphincterotomy. Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group. Recurrent anal fissure was observed in one patient (4 percent) after lateral internal sphincterotomy. At anal manometry, mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent, respectively. After pneumatic balloon dilatation, anal ultrasonography did not show any significant sphincter damage. At 24-month follow-up, the incidence of incontinence, irrespective of severity, was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group (P < 0.0001). CONCLUSIONS: As lateral internal sphincterotomy, pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence.

Adenocarcinoma of gastric cardia in the elderly: surgical problems and prognostic factors.

AIM: To analyze retrospectively, our results about patients who underwent surgical treatment for adenocarcinoma of the cardia in relation to age, in order to evaluate surgical problems and prognostic factors. METHODS: From January 1987 to March 2003, 140 patients with adenocarcinoma of the cardia underwent resection in the authors institution. They were divided into three groups with regard to age. Patients < 70 and > 60 year old (31) were excluded; we also excluded 18 out of 109 patients with poor general status or systemic metastases. So, we compared 51 elderly (> or = 70 year old) and 58 younger patients (> or = 60 year old). The treatment was esophagectomy for type I tumors, and extended gastrectomy and distal esophagectomy for type II and III lesions. RESULTS: Laparotomy was carried out in 91 patients (83.4%), 38 in the elderly (74.5%) and 53 in younger patients (91.3%, P<0.05). Primary resection was performed in 81 cases (89%) without significant differences between the two groups. Postoperative death was higher in the elderly (12.1%) than the other group (4.1%, P<0.05), while morbidity was similar in both groups. A curative resection (R0) was performed in 59 patients (72.8%), 69.6% in the elderly and 75% in the younger group (P>0.05). The overall 3- and 5-year survival rates were 26.7% and 17.8% respectively for the elderly and 40.7% and 35.1% respectively for younger patients (P=0.1544). Survival rates were significantly associated with R0 resection, pathological node-positive category and tumor differentiation in both groups. CONCLUSION: As the age of the general population increases, more elderly patients with gastric cardia cancer will be candidates for surgical resection. Age alone should not preclude surgical treatment in elderly patients with gastric cardia cancer and a tumor resection can be carried out safely. Certainly, we should take care in defining the surgical treatment in elderly patients, particularly as regarding the surgical approach; although the surgical approach does not influence the survival rate, the transhiatal way still remains the best one due, to the lower incidence of respiratory morbidity and thoracic pain.