Simultaneous totally robotic rectal resection and partial nephrectomy: case report and review of literature.

INTRODUCTION: The incidence of synchronous RCC and colorectal cancer is heterogeneous ranging from 0.03 to 4.85%. Instead, only one case of huge colon carcinoma and renal angiomyolipoma was reported. The treatment of synchronous kidney and colorectal neoplasm is, preferably, synchronous resection. Currently, laparoscopic approach has shown to be feasible and safe, and it has become the gold standard of synchronous resection due to advantages of minimally invasive surgery. We presented a case synchronous renal neoplasm and colorectal cancer undergone simultaneous totally robotic renal enucleation and rectal resection with primary intracorporeal anastomosis. As our knowledge, this is the first case in literature of simultaneous robotic surgery for renal and colorectal tumor. CASE PRESENTATION: A 53-year-old woman was affected by recto-sigmoid junction cancer and a solid 5 cm left renal mass. We performed a simultaneous robotic low anterior rectal resection and renal enucleation. Total operative time was 260 min with robotic time of 220 min; estimated blood loss was 150 ml; time to flatus was 72 h, and oral diet was administered 4 days after surgery. The patient was discharged on the eighth post-operative day without peri- and post-operative complication. The definitive histological examination showed a neuroendocrine tumor pT2N1 G2, with negative circumferential and distal resection margins. Renal tumor was angiomyolipoma. At 23 months follow-up, the patient is recurrence free. DISCUSSION AND CONCLUSION: As our knowledge, we described the first case in literature of simultaneous robotic anterior rectal resection and partial nephrectomy for treatment of colorectal tumor and renal mass. Robotic rectal resection with intracorporeal anastomosis surgery seems to be feasible and safe even when it is associated with simultaneous partial nephrectomy. Many features of robotic technology could be useful in combined surgery. This strategy is recommended only when patients' medical conditions allow for longer anesthesia exposure. The advantages are to avoid a delay treatment of second tumor, to reduce the time to start the post-operative adjuvant chemotherapy, to avoid a second anesthetic procedure, and to reduce the patient discomfort. However, further studies are needed to evaluate robotic approach as standard surgical strategy for simultaneous treatment of colorectal and renal neoplasm.

CD10 is useful to identify gastrointestinal contamination in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology from pancreatic ductal adenocarcinoma.

OBJECTIVE: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology is an effective tool to diagnose pancreatic ductal adenocarcinoma (PDA). Standard morphological criteria are usually reliable. When contaminating gastrointestinal (GI) epithelial cells are prevalent among neoplastic cells, these can be highlighted by carcinoembryonic antigen (CEA) staining. CD10 is a cell-surface metallopeptidase normally expressed by the GI epithelial apical border, whose expression is decreased or lost in PDA. We included CD10 in a panel, together with CEA, to discriminate the GI contaminant cells from PDA cells on cell blocks. METHODS: Eight cases of EUS-FNA of PDA, featuring both contaminating GI cells and neoplastic cells, whose corresponding cell blocks were available for immunostaining, were selected. CD10 and CEA were stained on cell blocks by standard methods. RESULTS: CD10 strongly labelled only the GI cells, with a well-defined apical membrane signal; conversely, GI cells did not show CEA staining; benign duodenal cells were faintly labelled in only one case. Malignant cells were positive for CEA and negative for CD10, with the exception of one case with labelled neoplastic cells with weak diffuse cytoplasmic positivity. CD10 apical membrane staining was a feature only seen in benign GI cells. CONCLUSIONS: As a loss of CD10 is a consistent feature of PDA, this marker can be useful, together with CEA, to aid the cytopathologist to identify neoplastic cells in a background rich in GI contaminant cells.

Impact of long-acting octreotide in patients with early-stage MEN1-related duodeno-pancreatic neuroendocrine tumours.

BACKGROUND: Somatostatin analogues (SSA) represent one of the main therapeutic option in patients affected with functioning well-differentiated neuroendocrine tumours (NETs). There are no studies specifically focusing on NETs associated with Multiple Endocrine Neoplasia type 1 (MEN1). AIM: To evaluate the efficacy of the long-acting SSA octreotide in MEN1 patients with early-stage duodeno-pancreatic NETs. PATIENTS AND METHODS: Forty patients with MEN1 were retrospectively evaluated. Twenty patients with evidence of one or more MEN1-related duodeno-pancreatic NETs < 20 mm in size (age range 26-61 years) were treated with octreotide long-acting octreotide (LAR) as first-line therapy. Treatment duration ranged 12-75 months. At the baseline radiological evaluation, multiple duodeno-pancreatic NETs (range 1-8, size 3-18 mm) were detected. RESULTS: An objective tumour response was observed in 10%, stable disease in 80% and progression of disease in 10% of cases. In six patients with abnormally increased CgA, gastrin and/or insulin serum concentrations, a significant clinical and hormonal response occurred in 100% of cases and was stable along the time. CONCLUSIONS: Therapy with SSA is highly safe and effective in patients with early-stage MEN1 duodeno-pancreatic NETs, resulting in long-time suppression of tumour and hormonal activity and 10% objective response. This suggests to early start therapy with SSA in patients with MEN1-related NETs.

Effect of preoperative chemoradiotherapy on outcome of patients with locally advanced esophagogastric junction adenocarcinoma-a pilot study.

BACKGROUND: To date, few studies of preoperative chemotherapy or chemoradiotherapy (crt) in gastroesophageal junction (gej) cancer have been statistically powered; indeed, gej tumours have thus far been grouped with esophageal or gastric cancer in phase iii trials, thereby generating conflicting results. METHODS: We studied 41 patients affected by locally advanced Siewert type i and ii gej adenocarcinoma who were treated with a neoadjuvant crt regimen [folfox4 (leucovorin-5-fluorouracil-oxaliplatin) for 4 cycles, and concurrent computed tomography-based three-dimensional conformal radiotherapy delivered using 5 daily fractions of 1.8 Gy per week for a total dose of 45 Gy], followed by surgery. Completeness of tumour resection (performed approximately 6 weeks after completion of crt), clinical and pathologic response rates, and safety and outcome of the treatment were the main endpoints of the study. RESULTS: All 41 patients completed preoperative treatment. Combined therapy was well tolerated, with no treatment-related deaths. Dose reduction was necessary in 8 patients (19.5%). After crt, 78% of the patients showed a partial clinical response, 17% were stable, and 5% experienced disease progression. Pathology examination of surgical specimens demonstrated a 10% complete response rate. The median and mean survival times were 26 and 36 months respectively (95% confidence interval: 14 to 37 months and 30 to 41 months respectively). On multivariate analysis, TNM staging and clinical response were demonstrated to be the only independent variables related to long-term survival. CONCLUSIONS: In our experience, preoperative chemoradiotherapy with folfox4 is feasible in locally advanced gej adenocarcinoma, but shows mild efficacy, as suggested by the low rate of pathologic complete response.

A multicenter phase II study of induction chemotherapy with FOLFOX-4 and cetuximab followed by radiation and cetuximab in locally advanced oesophageal cancer.

BACKGROUND: Preoperative chemoradiotherapy (CRT) improves the survival of patients with oesophageal cancer when compared with surgery alone. METHODS: We conducted a phase II, multicenter trial of FOLFOX-4 and cetuximab in patients with locally advanced oesophageal cancer (LAEC) followed by daily radiotherapy (180 cGy fractions to 5040 cGy) with concurrent weekly cetuximab. Cytokines levels potentially related to cetuximab efficacy were assessed using multiplex-bead assays and enzyme-linked immunosorbent assay at baseline, at week 8 and at week 17. Primary end point was complete pathological response rate (pCR). RESULTS: In all, 41 patients were enroled. Among 30 patients who underwent surgery, a pCR was observed in 8 patients corresponding to a rate of 27%. The most frequent grade 3/4 toxicity was skin (30%) and neutropenia (30%). The 36-month survival rates were 85 and 52% in patients with pathological CR or PR vs 38 and 33% in patients with SD or PD. CONCLUSIONS: Incorporating cetuximab into a preoperative regimen for LAEC is feasible; no correlation between cytokines changes and patient outcome was observed. Positron emission tomography/computed tomography study even if influenced by the small number of patients appears to be able to predict patients outcome both as early and late metabolic response.

Screening of pancreaticoduodenal endocrine tumours in patients with MEN 1: multidetector-row computed tomography vs. endoscopic ultrasound.

PURPOSE: The authors compared multidetector-row computed tomography (MDCT) and endoscopic ultrasound (EUS) in the identification of pancreaticoduodenal endocrine tumours (PETs) in patients with multiple endocrine neoplasia type 1 (MEN 1). MATERIALS AND METHODS: Fourteen consecutive patients (eight men and six women, aged 26-54 years) with MEN 1 underwent MDCT performed with a 4- (n=5) or 64- (n=9) detector-row system and EUS done with a radial transducer (7.5-20 MHz) within 7-28 days of each other. Prior to MDCT examination, patients were given 750 cc of water and asked to lie down in the right lateral decubitus for 15 min. Multiphase MDCT images were acquired both before and after the injection of nonionic iodinated contrast material (2 cc/kg) at an injection rate of 4 ml/s, with technical parameters and scan delay varying in relation to the system used. Images were all reconstructed at 3-mm intervals for the three phases (arterial, pancreatic and portal) and evaluated on a dedicated workstation. RESULTS: MDCT detected a total of 25 PETs (3-18 mm) in nine patients. Of these lesions, nine were situated within the duodenal wall and 16 in either the pancreatic head (n=3), body (n=7), or tail (n=6). Three additional lesions were detected retrospectively after EUS imaging. Most (18/22, 81%) were hypervascular nodules, and four appeared as either hypoattenuating or cystic lesions. EUS detected a total of 32 PETs (2-18 mm) in 11 patients. Most lesions (29/32, 90%) appeared hypoechoic and were situated in the duodenal wall (n=15) or in either the pancreatic head (n=10), body (n=6) or tail (n=1). CONCLUSIONS: Our preliminary data indicate that MDCT is complementary to EUS in the identification of PETs in MEN-1 patients.

[A retrospective analysis comparing colposuspension and retropubic mid-urethral sling as preventive anti-incontinence measures during laparoscopic sacrocolpopexy]. / Analisi retrospettiva di confronto tra colposospensione e sling retropubica medio-uretrale come misure preventive anti-incontinenza in corso di sacrocolpopessia laparoscopica.

AIM: The aim of this paper was to compare two anti-incontinence procedures during laparoscopic sacrocolpopexy (LSC) to prevent postoperative stress urinary incontinence (SUI). METHODS: Retrospective analysis of 90 continent hysterectomized patients with vaginal vault prolapse treated with LSC plus colposuspension (group A, N.=30), LSC plus retropubic mid-urethral sling (group B, N.=30), or LSC alone (group C, N.=30). RESULTS: De novo SUI rate resulted significantly (P<0.05) lower in group B than C. No difference was detected regarding de novo urge urinary incontinence. Total reoperation rate resulted significantly (P<0.05) higher in group A than B and lower in group B than C. CONCLUSION: When associated to LSC for preventing SUI, colposuspension and retropubic mid-urethral sling are effective and safe, even if mid-urethral sling seems to provide the best risk/benefit profile.

[The role of endoscopy in gastroenteropancreatic neuroendocrine tumors]. / Il ruolo dell'endoscopia nei tumori neuroendocrini gastroenteropancreatici.

Versione italiana Riassunto: Il ruolo dell'endoscopia nei tumori neuroendocrini gastroenteropancreatici. L. Magno, L. Sivero, V. Napolitano, S. Ruggiero, G. Fontanarosa, S. Massa I tumori neuroendocrini (NET) gastro-entero-pancreatici (GEP) sono neoplasie rare che originano dalle cellule neuroendocrine del tubo digerente e del pancreas. L'endoscopia digestiva e l'ecoendoscopia rivestono un ruolo importante nella diagnosi, stadiazione e sorveglianza dei pazienti con NET. Inoltre, in casi selezionati, le tecniche endoscopiche operative consentono il trattamento di queste neoplasie in fase precoce. English version Summary: The role of endoscopy in gastroenteropancreatic neuroendocrine tumors. L. Magno, L. Sivero, V. Napolitano, S. Ruggiero, G. Fontanarosa, S. Massa Gastroenteropancreatic (GEP) neuroendocrine tumors (NET) are rare neoplasia arisen from neuroendocrine cells present in the gut mucosa and pancreas. Digestive endoscopy and endoscopic ultrasonography play a relevant role in NET diagnosis, stadiation and surveillance. Moreover, in selected patients, surgical endoscopy allows the tratment of these cancers at an early stage.

Upper gastrointestinal massive bleeding successfully treated intra-operatively with a collagen and thrombin-based high-viscosity gel for haemostasis. Case report.

A 57-year-old male patient was admitted in our Department for a non-variceal upper gastrointestinal massive bleeding. In accordance with the clinical guidelines, the patient underwent an early endoscopy (within 24 hours from admission), which showed the source of bleeding in the second portion of the duodenum. An endoscopic haemostatic injection with dilute adrenalin (epinephrine, 1:10.000) was then performed. After 8 hours, severe recidive bleeding occurred with reduced haemoglobin levels, which led us to an emergency surgical treatment. A gastric resection was performed, followed by the application of high-viscous gel (Floseal) into the source of bleeding within the duodenal lumen. This technique allowed to obtain a definitive haemostasis without long-term complications. Our experience suggests that the intra-operative application of Floseal can be an effective alternative to traditional haemostatic techniques in the emergency surgical treatment of upper gastrointestinal bleeding. This also provides additional time to perform other haemostatic techniques techniques avoiding the precarious haemodynamic conditions of a patient in emergency.

[Presacral myelolipoma: a case report]. / Mielolipoma presacrale: case report.

BACKGROUND: Presacral tumors are more frequently benign, and only occasionally malignant, showing a slow growth and an incidence of 1:40.000. They are asymptomatic in the 26-50% of the cases. When symptoms occur, these are related to the dimensions of the tumor, to its location and to the presence of infection. CASE REPORT: We report the case of a 69-year old woman with a lower abdominal pain associated with paresthesia and ipostenia of the right inferior limb. Digital rectal examination showed a fixed, mild tender and hard tumor of the posterior rectal wall. CT, MR and CT-guided biopsy sequently performed revealed a solid, dishomogeneous mass, located in the presacral region, with a connective likely origin, without pelvic lymphoadenopathy. The operation allowed to esteem a mass which was tenaciously adherent to the sacrum. We performed a total excision. Final histological diagnosis was myelolipoma. CONCLUSIONS: The Authors' opinion is that the en-bloc resection of these tumors with an anterior surgical approach allows a histological diagnosis of the nature, representing the best treatment for potentially malignant lesions, which are frequently radio and chemo-resistant.

Clinical and instrumental parameters in patients with constipation and incontinence: their potential implications in the functional aspects of these disorders.

PURPOSE: The aims of this study were to evaluate several clinical and instrumental parameters in a large number of patients with constipation and incontinence as well as in healthy controls and discuss their potential implications in the functional aspects of these disorders. METHODS: Eighty-four constipated and 38 incontinent patients and 45 healthy controls were submitted to a protocol based on proctologic examination, clinico-physiatric assessment, and instrumental evaluation. RESULTS: Constipated and incontinent patients had significantly worse lumbar lordosis as well as lower rate in the presence of perineal defense reflex than controls. Constipated but not incontinent patients had a lower rate of puborectalis relaxation than controls. Furthermore, worse pubococcygeal tests and a higher rate of muscle synergies presence, either agonist or antagonist, were observed in both constipated and incontinent patients compared to controls. CONCLUSIONS: This study has demonstrated strong correlations between physiatric disorders and the symptoms of constipation and incontinence. Further studies designed to demonstrate a causal relationship between these parameters and the success of a specific treatment of the physiatric disorders on the proctology symptoms are warranted.

Colovesical fistulae in the sigmoid diverticulitis.

In most cases Colovesical fistulae are complications of diverticular disease and representing the most common kind of colodigestive fistula; less common are colovaginal, colocutaneous, coloenteric and colouterine fistula. In this article we review the literature concerning colovesical fistulae in colorectal surgery for sigmoid diverticulitis and report on two cases that required a surgical treatment, one elective and the other in emergency. In both cases we performed a sigmoid resection with a primary anastomosis and small vesical window-ectomy placing a Foley catheter for about 10 days.

[Abdominal compartimental syndrome as a complica-tion of Fournier's gangrene]. / Sindrome compartimentale addominale da gangrena di Fournier. Case report.

Analyzing a complex case and referring to the literature, the authors describe abdominal compartmental syndrome as a complication of Fournier's gangrene, stressing out the importance of an early diagnosis to perform prompt and effective treatment. The characteristic of this case is not represented only by the Fournier's gangrene rarity, but also by the appearance of an abdominal compartmental syndrome due to the gangrene extension from the scrotum to the abdominal wall and cavity through the spermatic funiculus. The treatment of the abdominal compartmental syndrome was the surgical toilette of the necrotic regions (scrotum, abdominal wall and cavity) together with an orchiectomy.

Objective assessment of gastroesophageal reflux after extended Heller myotomy and total fundoplication for achalasia with the use of 24-hour combined multichannel intraluminal impedance and pH monitoring (MII-pH).

This study aims to evaluate by the use of 24-hour combined multichannel intraluminal impedance and pH monitoring (MII-pH) the efficacy of the Nissen fundoplication in controlling both acid and nonacid gastroesophageal reflux (GER) in patients that underwent Heller myotomy for achalasia. It has been demonstrated that fundoplication prevents the pathologic acid GER after Heller myotomy, but no objective data exists on the efficacy of this antireflux surgery in controlling all types of reflux events. The study population consisted of 20 patients that underwent laparoscopic Heller myotomy and Nissen fundoplication for achalasia. All patients were investigated with manometry and MII-pH. MII-pH showed no evidence of postoperative pathologic GER. The overall number of GER episodes was normal in both the upright and recumbent position. This reduction was obtained because of the postoperative control of both the acid and nonacid reflux episodes. The Nissen fundoplication adequately controls both acid and nonacid GER after extended Heller myotomy. Further controls with MII-pH are warranted to check at a longer follow-up for the efficacy of this antireflux procedure in achalasic patients.

Total fundoplication does not obstruct the esophageal secondary peristalsis: investigation with pre- and postoperative 24-hour pH-multichannel intraluminal impedance.

AIM: To determine the impact of total fundoplication on the spontaneous esophageal clearance, known as secondary peristalsis. BACKGROUND: Although there is general agreement that total fundoplication is not an obstacle to bolus swallowing (primary peristalsis), whether it is an obstacle to spontaneous esophageal clearance (secondary peristalsis) is still not clear. Based on 24-hour monitoring, multichannel intraluminal impedance was used to calculate the time of spontaneous bolus clearance (BCT). METHODS: Mean BCT was prospectively calculated in 15 consecutive patients before and after total fundoplication. BCT was calculated in seconds including all the gastroesophageal reflux episodes, whereas bolus swallows (solid meals and liquid swallows) were excluded from the analysis. RESULTS: BCT was extrapolated from 1,057 episodes in the 623 h of study. Overall, BCT did not change after surgery (13.6 +/- 4 vs. 15.2 +/- 10 s; p = nonsignificant) and in the upright (12.2 +/- 3 vs. 16.5 +/- 7 s; p = nonsignificant) and recumbent position (22.9 +/- 9 vs. 23.0 +/- 9 s; p = nonsignificant). CONCLUSIONS: In this study total fundoplication did not affect the BCT by combined 24-hour ph monitoring and multichannel intraluminal impedance.

Acute appendicitis: a descending trend?

AIM: The diagnosis-related group (DRG) system is a prospective hospital payment system used to categorize hospital patients expected to require similar hospital services. In Italy, hospital productivity is calculated from DRG-based data coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which is a classification system for coding of diagnoses and operations for indexing medical records by diagnosis and operations. The aim of our survey was to determine the national incidence of appendectomies based on the coded summary of selected data in hospital discharge reports (HDR). METHODS: The Italian Ministry of Health online database was searched for data collected between 2001 and 2003. The search engine allows analysis by different regions but not by individual hospital. The national incidence of appendectomy was calculated using data collected from the ICD-9-CM and from the HDR. In a deeper analysis, regional data and data from individual hospitals were compared. RESULTS: The analysis revealed the incidence of appendectomy, rates of simple acute appendicitis vs complicated appendicitis, common laparotomic appendectomy vs laparoscopic appendectomy, as well as mean duration of hospitalization. CONCLUSION: The incidence of acute appendicitis has considerably decreased, whereas the rates of complicated appendicitis have increased because of longer diagnostic and therapeutic delay, inappropriate antibiotic therapy and upclassifying of diagnosis and procedures in the HDR (ICD-9-CM) in order to obtain a ''wider impact'' on DRG.

An unusual case of rectal carcinoid removed by transanal endoscopic microsurgery.

The name ''carcinoid'' was invented by Oberndorfer in 1907, when the nature of those histological entities was little understood. Usually, they were found in various locations in the gastrointestinal (GI) apparatus (67%), most of them in the small intestine (25%), appendix (12%), and rectum (14%).The techniques used for their removal are various. The authors present here a case of rectal carcinoid removed using the transanal endoscopic microsurgery technique, and referred to the diagnosis and treatment of this uncommon tumor. A 37-year-old male was admitted to the Santa Maria Hospital of Terni (Italy) with a chief complaint of intermittent pain in the lower right quadrant, that began three years ago. Complete blood count (CBC) and laboratory data as tumor markers and urinary 5-hydroxyindoleacetic acid (5-HIAA) showed no abnormalities, while urinary vanilmandelic acid level was elevate (18 mg/24 h). The patient was submitted to a colonoscopy with magnifying endoscopy and biopsy. The histological finding demonstrated a nodule characterized by cellular proliferation, with few microscopical abnormalities, arranged in small cords with a glandular pattern, separated by dense connective tissue. Histochemically the tumor cells were cytocheratins +/-, chromogranin positive, synaptophysine positive, CD56 positive and Growth Index MIB1-Ki67 which was almost zero. The patient also underwent an endoscopic ultrasonography and an Octreoscan. He was operated using a transanal endoscopic microsurgery technique. The use of Transanal Endoscopic Microsurgery (TEM) as a safe and feasible technique for exciding rectal tumors can be easily understood, for the excellent view and precise dissection. The use of new surgical devices as Harmonic Scalpel has improved the precision of this kind of approach, increasing the appropriateness of this approach compared to other kind of resection. A full diagnostic course and an immunohistochemistry are mandatory for precise diagnosis of rectal carcinoid. Careful attention must be paid to these tumors because of their unexpected behaviour.

[Laparoscopic cholecystectomy for acute cholecystitis]. / La colecistectomia laparoscopica nel trattamento della colecistite acuta.

BACKGROUND: The aim of this study is to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to determine the optimal timing. PATIENTS AND METHODS: The study was performed in two groups of 70 consecutive patients (similar in age and ASA classification), retrospectively reviewed, who had been diagnosed with acute cholecystitis and were underwent early or delayed laparoscopic cholecystectomy. In early group surgery took place within 48 hours of admission in hospital. The interval for delayed laparoscopic cholecystectomy was 8-12 weeks after medical treatment. RESULTS: In delayed group 21,4% of patients required urgent surgery after failure of conservative treatment. The most important significant difference is the total hospital stay: the early group had a significant shorter hospital stay (7 days) vs delayed group (13 days). Other differences were the conversion rate (8,6% in early group vs 12,7% in delayed group) and median the operation time (84 min. in early group vs 106 min. in delayed group). Post-operative complications developed in 6,3% in early group vs 2,6% in delayed group. CONCLUSION: The optimal treatment of acute cholecystitis is urgent laparoscopic cholecystectomy but in our experience early laparoscopic cholecystectomy increased postoperative morbidity in hospital decreased conversion rate, median operation time and hospital stay.

Enfrentamiento de lesiones de cavidad oral: clasificación y diagnóstico diferencial / Assessment of oral cavity lesions: classification and differential diagnosis

Las lesiones de la cavidad oral corresponden a un hallazgo frecuente y muchas veces difíciles de diagnosticar. Su correcto reconocimiento podría ser clave en detectar patologías que podrían cambiar el pronóstico del paciente. El objetivo de esta revisión es describir una clasificación de las lesiones de la cavidad oral que permita ayudar al diagnóstico en la práctica clínica. Para esto, se detallan y se describen las lesiones, orientando al diagnóstico y a la necesidad de biopsiar. Para simplificar la orientación diagnóstica, las lesiones se clasifican en 2 grandes grupos: tumorales y no tumorales. Las lesiones no tumorales se subdividen en lesiones de la mucosa oral y lesiones de la lengua.

Lesions of the oral cavity are frequent and often difficult to diagnose. However, correct recognition could change the patient's prognosis. This review aims to describe a classification of oral mucosa lesions, to help the diagnosis in clinical practice. The lesions are described for this, guiding the diagnosis and the need for biopsy. To simplify the diagnostic orientation, the lesions are classified into two groups: tumor and non-tumor lesions. Non-tumor lesions are subdivided into lesions of the oral mucosa and lesions of the tongue.

Influence of age on outcome of total laparoscopic fundoplication for gastroesophageal reflux disease.

AIM: To demonstrate that age does not influence the choice of treatment for gastroesophageal reflux disease (GERD). We hypothesized that the outcome of total fundoplication in patients > 65 years is similar to that of patients aged < or = 65 years. METHODS: Four hundred and twenty consecutive patients underwent total laparoscopic fundoplication for GERD. Three hundred and fifty-five patients were younger than 65 years (group Y), and 65 patients were 65 years or older (group E). The following elements were considered: presence, duration, and severity of GERD symptoms; presence of a hiatal hernia; manometric evaluation, 24 h pH-monitoring data, duration of operation; incidence of complications; and length of hospital stay. RESULTS: Elderly patients more often had atypical symptoms of GERD and at manometric evaluation had a higher rate of impaired esophageal peristalsis in comparison with younger patients. A mild intensity of heartburn often leads physicians to underestimate the severity of erosive esophagitis. The duration of the operation was similar between the two groups. The incidence of intraoperative and postoperative complications was low and the difference was not statistically significant between the two groups. An excellent outcome was observed in 92.9% young patients and 91.9% elderly patients. CONCLUSION: Laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients, warranting low morbidity and mortality rates and a significant improvement of symptoms comparable to younger patients.