Thymic hyperplasia is accurate to detect new-onset Graves' hyperthyroidism and resolves after restoring euthyroidism.

PURPOSE: Abnormal liver blood tests (ALBTs), neutropenia (NEU) and thymic hyperplasia (TH) are new features of Graves' disease (GD). Our objectives were: (a) to calculate the accuracy of TH in discriminating between Graves' and non-Graves' thyrotoxicosis, compared to ALBTs, NEU and Graves' orbitopathy (GO); (b) to explore the outcome of GD-associated TH and non-GD-associated TH. METHODS: We prospectively analyzed consecutive adult patients with newly diagnosed thyrotoxicosis from January 2018 to June 2023. TH was detected via neck ultrasound (nUS) then confirmed and followed by magnetic resonance imaging (MRI). For GD vs non-GD clinical sensitivity (SE) and specificity (SPEC), accuracy, positive predictive value (PPV) and negative predictive value (NPV) of GO, TH, ALBTs and NEU were calculated. RESULTS: 264 thyrotoxic patients were included. TH was found in 16.4% (20/122) of GD vs 1.4% (2/142) in non-GD (p < 0.001). SE, SPEC, accuracy, PPV and NPV of the four extrathyroidal manifestations of GD were as follows, respectively: GO 26%, 100%, 66%, 100%, 61%; ALBTs 41%, 89%, 69%, 76%, 66%; NEU 5%, 100%, 56%, 100%, 55%; TH 16%, 98%, 61%, 91%, 98%. In 18 of them, TH regressed within 12 months after achieving euthyroidism under anti-thyroid drug therapy, while in the remaining 2, TH regressed 6 months after thyroid surgery. In the two non-GD patients with TH, thymus disappeared along with euthyroidism. CONCLUSIONS: TH in the hyperthyroidism scenario provides a high PPV for GD. A conservative approach for the diagnostic work-up and initial management of thyrotoxicosis-associated TH should be adopted.

Mesenteric cyst and recurrent abdominal pain in a patient with Gorlin-Goltz syndrome: a case report.

Gorlin-Goltz syndrome (GGS) is an infrequent autosomal do-minant multisystemic disease with complete penetrance and variable expressivity. It is estimated to have an incidence of 1:50,000 - 1:150,000 cases with a M/F = 1:1. This report describes a case of recurrent abdominal pain due to a large mesenteric cyst in a 38-year-old female patient affected by a rare disease: Gorlin-Goltz syndrome.

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.

Complete response to preoperative chemoradiation and survival in esophageal cancer: a pooled analysis of three single-institution phase II trials.

This pooled analysis was performed using individual patient data from three phase II trials that included on the whole 113 esophageal cancer treated preoperatively with chemoradiotherapy (CRT), in order to analyze the efficacy and survival outcomes according to the achievement of the pathologic complete response (pCR). Thirty-nine patients were treated with 5-fluorouracil/cisplatin and RT (40 Gy), 33 patients received paclitaxel/cisplatin weekly during weeks 1-6 with and RT (46 Gy), 41 patients were treated with induction bio-chemotherapy with cetuximab and FOLFOX-4 followed by concomitant cetuximab and RT of 50.4 Gy. One hundred and two out of 113 resected patients were included in the survival analysis. The median overall survival (OS) time for the whole population was 21.5 months. The 12, 24, and 36 months OS rates were 85.4, 45.2, and 33%, respectively. The difference in survival probability between patients with pCR and patients with partial response or stable disease after treatment was significant (P= 0.0002, hazard ratios = 0.21, 95% CI 0.18-0.60). On multivariate analysis, the pathologic response and histology were the only covariates independently associated with OS (P= 0.0157 and P= 0.0212, respectively). In our series, complete responder patients had a significant longer survival probability after treatment when compared to patients with partial response or stable disease.

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.

Search for compensation postures with videofluoromanometric investigation in dysphagic patients affected by amyotrophic lateral sclerosis.

PURPOSE: This study was undertaken to verify the effectiveness of compensatory postures, suggested on the basis of the type of dysphagia identified at videofluoromanometric (VFM) investigation to ensure safe oropharyngeal transit. MATERIALS AND METHODS: Eighty-one patients with amyotrophic lateral sclerosis (ALS) underwent speech therapy assessment and VFM investigation of the swallowing process. In the event of altered transit, penetration or aspiration of contrast material into the airways, compensation postures for correction of the swallowing disorder were suggested and verified during VFM examination. RESULTS: In 37 patients, contrast agent transport was preserved and safe; in 19, we observed penetration of the contrast agent into the laryngeal inlet without aspiration; in 24, there was aspiration (four preswallowing, eight intraswallowing, nine postswallowing, three mixed), whereas in one patient no transit was seen. Penetration without aspiration was resolved by coughing or throat clearing; aspiration was resolved in 13 patients by assuming the chin-tuck posture and in six by rotating the head; in five patients, it was not resolved. A hyperextended head posture proved to be effective to resolve lack of transit. CONCLUSIONS: By correlating morphological with functional data, VFM enables one not only to precisely characterise the dysphagic disorder but also to identify the most appropriate compensation posture for each patient and verify its effectiveness.

Diagnostic value of arterial blood gas lactate concentration in the different forms of mesenteric ischemia.

PURPOSE: The role of serum lactate measurement in patients with intestinal ischemia still remains unclear. The aim of this study was to prospectively evaluate the diagnostic performance of arterial blood gas lactate concentrations in the patients with acute mesenteric ischemia and its different forms. METHODS: All the patients reporting abdominal pain associated with risk factors for mesenteric ischemia underwent arterial blood gas and contrast enhanced abdominal computer tomography (CT). RESULTS: At CT, 201 patients (70.7%) showed a nonischemic disease (group 1) and 83 patients (29.2%) showed findings of mesenteric ischemia. Out of these, 35 patients (42.1%) showed bowel ischemia secondary to non vascular causes (group 2) and 48 (57.8%) had a vascular intestinal ischemia (group 3). Out of these, 20 showed small bowel arterial occlusion (group 3a), 13 a small bowel nonocclusive ischemia (group 3b), 7 a venous small bowel occlusion (group 3c) and 8 showed isolated colonic ischemia (group 3d). The median lactate serum level was significantly higher in patients with vascular ischemia if compared with patients with nonischemic disease and secondary mesenteric ischemia (p < 0.0001; Kruskal-Wallis test). The areas under ROC curves for the lactate serum levels in the groups 2, 3, 3a, 3b, 3c and 3d were, respectively, 0.61, 0.85, 0.93, 0.93, 0.68 and 0.67. CONCLUSIONS: Arterial blood gas lactate levels seem to show good diagnostic accuracy in diagnosing small bowel arterial and nonocclusive ischemia and poor accuracy in diagnosing secondary mesenteric ischemia, small bowel venous ischemia and ischemic colitis.

Detecting a rare composite small bowel lymphoma by Magnetic Resonance Imaging coincidentally: A case report with radiological, surgical and histopathological features.

INTRODUCTION: Diagnosing lymphoma continues to prove challenging in the clinical practice. Composite lymphoma (CL) is defined by the coexistence of different lymphoma subtypes in the same anatomical location. This condition has seldom been witnessed in the gastrointestinal (GI) tract. We weren't able to find previous cases in the literature about small bowel CL with follicular lymphoma (FL) and classical Hodgkin lymphoma (CHL). Surgery is the treatment of choice to obtain accurate histology, to manage and prevent acute complications. We state that this work has been reported in line with the SCARE criteria. CASE PRESENTATION: We describe an extremely rare case of small bowel CL, presenting as an intestinal bulky mass with circumferential infiltration of bowel loops. The small bowel tumor was incidentally detected by abdominal Magnetic Resonance Imaging (MRI) in a 64-year-old man who suffered from rectal discomfort and non-specific clinical symptoms. After this radiological finding, the patient underwent multiphase contrast computed tomography (MDCT) for initial staging and to study vascular involvement. Surgery was recommended to obtain an accurate diagnosis both due to initial symptoms of the intestinal obstruction and to avoid small bowel complications. The histopathological examination revealed a small bowel CL composed mainly of B cells FL with also CHL components. CONCLUSION: It is important to note that involvement of the proximal ileal loops is very rare in small bowel lymphoma. MRI represents a precious diagnostic tool to evaluate the intra and extramural extent of the tumor.

Cinedefecographic findings in patients with obstructed defecation sindrome. A study in 420 cases.

AIM: Obstructed defecation syndrome (ODS) represents a very common clinical problem. The aim of this study was to analyze the cinedefecographic findings in a group of patients with ODS. METHODS: All patients with ODS were prospectively introduced into a database and underwent cinedefecography (CD). The grade of the syndrome was assessed by a new ODS score. The validated Agachan-Wexner Constipation Score System was also used. Four lateral films were taken during resting, squeeze, pushing and postevacuation phases and puborectalis length (PRL), anorectal angle (ARA) and perineal descent were recorded and analysed. The presence of an increased fixed perineal descent (FPD) and dynamic perineal descent (DPD), mucosal rectal prolapse (MRP), recto-rectal intussusception (RRI), recto-anal intussusception (RAI), rectocele (RE), enterocele (ET) and sigmoidocele (SG) were also evaluated. RESULTS: Between February 2002 and March 2005, 420 patients, 404 (96.1%) females and 16 (3.8%) males with a mean age of 49+/-7.7 (range, 21-77) years, underwent CD. In 362 (86.2%) patients CD showed a combination of different cinedefecographic findings. RE, FPD and DPD in association with RAI or RRI were contemporary observed in 118 (26%) patients. MRP, RRI, FPD, RAI and RE were observed as singular finding in 21 (5%), 19 (4.5%), 12 (2.8%), 3 (0.7%) and 3 (0.7%) patients, respectively. In 6 (1.4%) patients a paradoxical contraction of the puborectalis muscle was observed. CONCLUSIONS: CD shows that ODS is largely caused by multiple patterns of different abnormalities of the rectum and pelvic floor. Any treatment in symptomatic patients could be designed to treat multiple combinations of different abnormalities.

Surgical management of advanced gastric cancer: An evolving issue.

Worldwide, gastric cancer represents the fifth most common cancer and the third leading cause of cancer deaths. Although the overall 5-year survival for resectable disease was more than 70% in Japan due to the implementation of screening programs resulting in detection of disease at earlier stages, in Western countries more than two thirds of gastric cancers are usually diagnosed in advanced stages reporting a 5-year survival rate of only 25.7%. Anyway surgical resection with extended lymph node dissection remains the only curative therapy for non-metastatic advanced gastric cancer, while neoadjuvant and adjuvant chemotherapies can improve the outcomes aimed at the reduction of recurrence and extension of survival. High-quality research and advances in technologies have contributed to well define the oncological outcomes and have stimulated many clinical studies testing multimodality managements in the advanced disease setting. This review article aims to outline and discuss open issues in current surgical management of advanced gastric cancer.

Gastric cancer in the elderly patient.

The incidence of gastric cancer is increasing in elderly patients, unlike what it's being observed in the younger patients. The aim of this study is to evaluate the impact of the age on the resecability, resection type (R0-R1-2), morbidity, mortality and survival rate. The higher mortality observed in the elderly patients, the discussed role of an extended lymphadenectomy and the poor survival rate, would lead to a surgical approach which mostly tends to the palliation of the symptoms than the obtainment of a curative resection. But, on the other hand, the impossibility of making chemotherapy in most of the over 75 year old patients, lead us to a R0 surgery treatment.

Standards for oesophageal manometry. A position statement from the Gruppo Italiano di Studio Motilità Apparato Digerente (GISMAD).

Manometry is an important tool in the diagnosis of oesophageal motility, disorders, but proper instruments and methods are needed to obtain useful clinical information. The authors reviewed the minimal technical requirements, operative aspects, which information the final report should contain as well as indications and contraindications of the text itself. Technical requirements: At least a three-channel, multiple-lumen catheter perfused with a pneumo-hydraulic capillary infusion system which ensures deltaP/deltaT>150-200 mmHg/sec.; data should be recorded at a sampling rate of > or =8 Hz to study the oesophageal body and lower oesophageal sphincter; lower oesophageal sphincter tonic (pressure) and phasic activity (relaxations) and oesophageal body amplitude and peristaltic activity should be recorded. The final report must contain the patient's details, the indication for the test and a manometric diagnosis. Indications for manometry: Dysphagia (after ruling out any organic pathology); non- cardiac chest pain (after ruling out any cardiopulmonary involvement); systemic collagenosis (to investigate oesophageal involvement); gastro-oesophageal reflux disease (if surgery is planned). Contraindications are limited to: pharyngeal or upper oesophageal obstructions, oesophageal bullous disorder, cardiac conditions in which vagal stimulation may not be tolerated, severe coagulopathy and patient non-compliance.

Well differentiated "lipoma-like" liposarcoma of the sigmoid mesocolon and multiple lipomatosis of the rectosigmoid colon. Report of a case.

Liposarcoma is the second most common soft tissue sarcoma in adults. These neoplasms take their origin from primitive mesenchymal cells and are rarely encountered in fat rich areas, such as subcutaneous tissue and/or the subserosa of the intestinal tract which, on the contrary, are the two most common sites of lipomas. The two major locations of liposarcomas are the extremities and the retroperitoneum followed with much less frequency by the inguinal region. Other sites are uncommon, particularly the mesentery (9 cases to date in the literature) and, even more so, the mesocolon (only 3 cases of primary sarcoma of the mesocolon reported to date). This paper reports on the case of a well differentiated "lipoma-like" liposarcoma of the sigmoid mesocolon, associated with multiple lipomatosis of the recto-sigmoid colon in a 75 year-old female patient. Surgical treatment consisted of a trans-anal extra-peritoneal anterior resection by CEEA 28 stapler under endoscopic vision. The patient has been followed up for the last 2 years and is still disease-free and well. The peculiarity of the case consists in the contemporaneous presence in close contiguity of two different rare neoplasms whose association is not yet known.

[Surgical treatment of esophageal achalasia by Heller+Nissen laparoscopic procedure. A 24-hour ambulatory esophageal manometry study]. / Il trattamento chirurgico dell'acalasia esofagea mediante Heller + Nissen laparoscopica. Studio mediante manometria ambulatoriale di 24 ore.

BACKGROUND: The aim of this work was to evaluate, by means of a 24-h esophageal manometry, the motor activity of esophageal body in achalasic patients before and after Heller's myotomy and Nissen's fundoplication. METHODS: Twenty-five achalasic patients underwent a 24-h esophageal manometry. After surgical treatment they had a further 24-h esophageal manometry during follow-up. RESULTS: A statistically significant increase of amplitude of contraction and an increase, but not statistically significant, of frequency and duration of contractions were observed. The study of peristaltic activity showed an increase of peristaltic activity in total and complete sequences and decrease of dropped and interrupted peristaltic sequences. CONCLUSIONS: These data surprisingly showed the presence of a peristaltic activity (31.2%), in achalasic esophageal body, and complete sequences in 20%. The improvement of peristaltic activity observed after surgical abolition of the functional sphincteral rub, proposes again the question about the fall of the peristaltic activity of the esophageal body, which could be due to the hard transit through the LES. This preliminary data seem to confirm, in qualitative and quantitative manner, the positive effect of Heller's myotomy and the null effect of Nissen's fundoplication on the esophageal transit.

[Behavior of the pressure of the lower esophageal sphincter after intravenous administration of domperidone in normal subjects]. / Comportamento della pressione dello sfintere esofageo inferiore (LES-P) dopo somministrazione intravenosa di domperidone in soggetti normali.

Manometric studies on the action of domperidone 10 mg and 20 mg i.v. on the lower esophageal sphincter pressure (LESP) have been carried on ten healthy volunteers. Domperidone inhibits dopamine receptors and results in an increase of LESP. A dose of 10 mg produces a significant increase in LESP which is rapid and prolonged for thirty minutes; a dose of 20 mg is less efficient. The stimulatory effect of domperidone on LESP suggests an important role for endogenous dopamine as an inhibitory neuromodulator of LES pressure. The use of domperidone in therapy for reflux esophagitis is suggested.

[Intraoperative esophageal manometry in the surgical treatment of achalasia]. / Manometría esofágica intraoperatoria en el tratamiento quirúrgico de la acalasia.

Since 1985 we have done intraoperative manometry in 54 patients operated for achalasia. Manometry allows the assessment of the completeness of the division of the high pressure zone and ascertain the length of fundoplication (Nissen) as well as its pressure. In 26 patients pH and manometric controls were done postoperatively. Absence of reflux was noted in all and the pressure level after operation was 12.53 +/- 4.94 mmHg. Pressure measurements were not different from those of a group of 15 healthy subjects (15.2 +/- 2.45 mmHg). Dynamic studies of the high pressure zone revealed a post-deglutition relaxation of 72.5 +/- 16.32% over the basal tone. We believe that intraoperative manometry is essential in the surgical treatment of achalasia as it allows a precise control of myotomy as well as the fashioning of a high pressure zone to avoid reflux.

[Evaluation of esophageal function in surgically-treated patients]. / Valutazione funzionale esofagea del paziente operato.

The authors report on their experience acquired in the surgical treatment of functional esophageal disease (achalasia, diffuse esophageal spasm, diverticula and gastroesophageal reflux). The authors affirm that a correct and meticulous functional study of the esophagus is fundamental for the adoption of precise surgical plotting, in order to circumvent all of the complications and failures described in Literature. Such an objective can be achieved intraoperatively thanks to myotomy and fundoplication with the aid of intraoperative manometry (IEM) that, when performed in the course of myotomy, circumvents the execution of incomplete procedures (incomplete myotomies). The same holds true in the case of anti-reflux plasty (Nissen's in particular) where IEM enables a plication that is neither too wide nor too narrow, too long, too short, but "calibrated". Then, instrumental probes are even more capable of assessing the effects of functional surgery, by enabling the documentation of perfect postoperative results. More precisely they make it possible to study patients presenting with motor disorders pre-operatively, as in the case of achalasia or diverticula, and to sanction their resolution postoperatively. In addition they enable documentation of the effectiveness of Nissen's fundoplication, performed either to prevent gastroesophageal reflux after myectomy or to treat primary reflux. This is made possible by studying not only the tone at a distance, but especially relaxation in the course of deglutition. Finally, pH-metry permits the documentation of the complete clearing of gastroesophageal reflux, even when physiologic and post-prandial (hypercompetent Nissen).

[Antithrombotic prophylaxis in day surgery: proposal of a clinical protocol]. / La profilassi antitrombotica in day surgery. Proposta di un protocollo clinico.

The considerable diffusion of the day surgery has new problems such as the use of antithrombotic prophylaxis, now carried out systematically in major surgery. An the basis of the poor data present in the literature, a protocol of study is proposed to evaluate the real effectiveness of this type of prophylaxis in DS, dividing the patients into 3 groups, according to the patient's risk factors to the intervention and to the disease.

[Failure of surgical treatment for achalasia: diagnosis and treatment]. / Insuccessi della terapia chirurgica dell'acalasia: diagnosi e trattamento.

After a wide revision of the Literature, the most frequent causes of failure in the surgical therapy of esophageal achalasia are described. Above all there is the uncorrect execution of the Heller's myotomy as for its upward and downward extension or its deepness. An uncorrect myotomy, in fact, might cause the persistence or relapse of pre-operative symptoms, such as dysphagia and regurgitation. A correct myotomy, according to the authors, should be always carried out with the aid of intraoperative manometry (IEM), which allows the documentation of the alterations caused by surgery in the area of the high pressure zone, which corresponds to the sphincter (LES). A correct myotomy must produce the complete annulment of such a pressure. This technique creates the conditions sufficient to the genesis of gastroesophageal reflux (GER), which is one of the most frequent causes of failure in the surgery of achalasia. In fact, it causes a reflux esophagitis which can quickly evolve into a stricture with the reappearance of dysphagia. It is essential, therefore, to combine always the Heller's procedure with an antireflux procedure, which can protect the esophagus from GER and at the same time does not produce a mechanical obstacle to deglutition. The Authors report their last experience based on 114 primary operations of Heller's myotomy + Nissen fundoplication, performed since 1985 to date. IEM has been always used both for controlling the completeness of the myotomy and for the "calibration" of the Nissen's. Two patients, which had undergone elsewhere a Heller's myotomy alone, have been operated of re-myotomy + Nissen fundoplication. One patient, also operated elsewhere of myotomy of the esophageal body for diffuse esophageal spasm (DES), complained of dysphagia and had manometrical evidence of LES dischalasia; this patient has been reoperated of Heller's myotomy + Nissen fundoplication; another patient suffering from a reflux stricture after a Heller's myotomy without antireflux procedure, has been treated with a Roux esophago-jejunostomy. A last patient operated by Heller's myotomy + Dor fundoplication presented alkaline esophagitis without dysphagia; the treatment consisted in a Roux gastro-jejunostomy + bilateral troncular vagotomy. These data bring to the conclusion that the best treatment of achalasia relapses is their prevention, only obtainable by a good primary therapeutic approach and the routine use of IEM. The IEM avoids incomplete myotomies and inadequate antireflux procedures related to the incompetence (reflux) or hypercompetence (dysphagia recurrence) of the fundoplication.