The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review.

BACKGROUND: The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT). METHODS: We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS: Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively. CONCLUSIONS: The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper.

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann's procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

Abnormal gut motility in inflammatory bowel disease: an update.

BACKGROUND: There is substantial evidence linking disturbed gastrointestinal motility to inflammation. Thus, it is not surprising that abnormalities of gastrointestinal motility play a role in inflammatory bowel disease (IBD), affecting patient outcomes. We performed a review of the literature to investigate the relationship between abnormal gut motility and IBD. METHODS: With an extensive literature search, we retrieved the pertinent articles linking disturbed gut motility to IBD in various anatomical districts. RESULTS: The evidence in the literature suggests that abnormal gastrointestinal motility plays a role in the clinical setting of IBD and may confuse the clinical picture. CONCLUSIONS: Abnormal gut motility may be important in the clinical setting of IBD. However, additional data obtained with modern techniques (e.g., magnetic resonance imaging) are needed to individuate in a more precise manner gastrointestinal motor dysfunctions, to understand the nature of clinical manifestations and properly tailor the treatment of patients.

Hospital admission for complicated diverticulitis is increasing in Italy, especially in younger patients: a national database study.

BACKGROUND: Epidemiological studies show an increasing trend of hospitalization for acute diverticulitis (AD), but data regarding the trend in hospitalization for complicated AD in Italy are scarce. The aim of this study was to analyze the Italian trend in hospitalization for complicated AD, from 2008 to 2015. METHODS: Using the Italian Hospital Information System, we identified all patients with complicated colonic AD as a discharge diagnosis. Age- and sex-specific rates for AD as well as type of hospital admission (emergency/elective), type of complication (peritonitis, obstruction, bleeding, abscess, fistula, perforation, sepsis) and type of treatment (medical/surgical), were analyzed. RESULTS: A total of 41,622 patients with a discharge diagnosis of complicated AD were identified. Over the study period the admission rate grew from 8.8 to 11.8 per 100,000 inhabitants. The hospitalization rate was highest for patients ≥ 70 years, but the increase in the admission rate was higher among patients aged ≤ 60 years. There were more males in the group < 60 years and more females in the group ≥ 60 years old. The rate of emergency admissions associated with surgery showed a significant mean annual increase (+ 3.9% per year) in the rate of emergency admissions associated with surgery, whereas elective admissions for surgery remained stable. Peritonitis was the most frequent complication (35.5%). The rate of surgery increased in AD complicated by peritonitis (+ 5.1% per year), abscess (+ 5.8% per year) and decreased for obstruction (- 1.8% per year). CONCLUSIONS: From 2008 to 2015, we documented an increasing rate of hospitalization for complicated AD, especially for younger patients, with an increase in surgery for peritonitis and abscess. Further studies are needed to clearly assess the risk factors for complications and risk of surgery.

Multicentre international trial of laparoscopic lavage for Hinchey III acute diverticulitis (LLO Study).

BACKGROUND: Laparoscopic lavage was proposed in the 1990s to treat purulent peritonitis in patients with perforated acute diverticulitis. Prospective randomized trials had mixed results. The aim of this study was to determine the success rate of laparoscopic lavage in sepsis control and to identify a group of patients that could potentially benefit from this treatment. METHODS: This retrospective multicentre international study included consecutive patients from 24 centres who underwent laparoscopic lavage from 2005 to 2015. RESULTS: A total of 404 patients were included, 231 of whom had Hinchey III acute diverticulitis. Sepsis control was achieved in 172 patients (74·5 per cent), and was associated with lower Mannheim Peritonitis Index score and ASA grade, no evidence of free perforation, absence of extensive adhesiolysis and previous episodes of diverticulitis. The operation was immediately converted to open surgery in 19 patients. Among 212 patients who underwent laparoscopic lavage, the morbidity rate was 33·0 per cent; the reoperation rate was 13·7 per cent and the 30-day mortality rate 1·9 per cent. Twenty-one patients required readmission for early complications, of whom 11 underwent further surgery and one died. Of the 172 patients discharged uneventfully after laparoscopic lavage, a recurrent episode of acute diverticulitis was registered in 46 (26·7 per cent), at a mean of 11 (range 2-108) months. Relapse was associated with younger age, female sex and previous episodes of acute diverticulitis. CONCLUSION: Laparoscopic lavage showed a high rate of successful sepsis control in selected patients with perforated Hinchey III acute diverticulitis affected by peritonitis, with low rates of operative mortality, reoperation and stoma formation.

Trends in hospital admission for acute diverticulitis in Italy from 2008 to 2015.

BACKGROUND: Epidemiological studies in Western countries have documented an increase of hospitalizations for acute diverticulitis (AD) but Italian evidence is scarce. The aim of the present study was to analyse the trend in hospitalization for AD, including in-hospital mortality, in Italy from 2008 to 2015. METHODS: Through the Italian Hospital Information System of the National Health System, we identified diverticulitis of the colon as a discharge diagnosis. Age- and gender-specific rates of hospitalization for AD were assessed. RESULTS: 174,436 hospitalizations were identified with an increasing rate in 2008-2015 from 39 to 48 per 100,000 inhabitants (p < 0.001). The rate of hospitalization was higher for women, but the increasing trend over time was even more pronounced among men (mean increase per year 3.9% and 2.1% among men and women, respectively) (p < 0.001). The increased rate of hospitalization was accounted for by patients less than 70 years old, especially those under 60. In contrast, the hospitalization rate for older patients (age ≥ 70 years) was higher but remained unchanged during the study period. The number of patients with one hospital admissions was significantly higher than the number of patients with at least two hospitalizations (p < 0.001) and both groups showed a significant and comparable increase year by year. The overall in-hospital mortality rate increased from 1.2 to 1.5% (p = 0.017). More specifically, the increase was observed in patients at their first hospitalization [from 1 to 1.4% (mean increase per year of 3%, p = 0.003)]. An increase in mortality was most evident among women (from 1.4 to 1.8% p = 0.025) and in older patients [age 70-79 years from 1.2 to 1.7% (p = 0.034), ≥ 80 years from 2.9 to 4% (p = 0.001)]. CONCLUSIONS: In Italy, between 2008 and 2015, the rate of hospitalization for AD has been constantly increasing due to the hospitalization of younger individuals, especially men. There was a significant increase of in-hospital mortality especially among women, elderly and during the first hospitalization. These findings suggest the need for increased awareness and clinical skills in the management of this common condition.

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines.

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.

Colonic lymphoid follicles and NOD2/CARD15 mutational status in Crohn's disease.

BACKGROUND: Interactions between the colonic lymphoid system and the genetic background in Crohn's disease are unexplored. This study analysed variations of colonic lymphoid follicles (CLFs) according to the nucleotide-binding oligomerization domain 2 (NOD2) and caspase recruitment domain-containing protein 15 (CARD15) gene in patients with Crohn's disease. METHODS: CLFs were characterized by histology and immunohistochemistry in the specimens of 41 patients undergoing colonic resection for Crohn's disease. Variants of the NOD2/CARD15 gene were assessed by denaturing high performance liquid chromatography and confirmed by DNA sequencing. RESULTS: Eleven patients had a heterozygous variant of the NOD2/CARD15 gene. The uninvolved colon of mutants had significantly lower CLF density (0.9 versus 2.7 follicles per cm(2); P < 0.001) and proportion of those with a germinal centre (9 versus 22 per cent; P = 0.040) than in non-mutants. In active disease, CLF density increased similarly in patients with and without the mutation. The proportion of extramucosal CLFs was higher in mutants than in non-mutants (34 versus 22 per cent; P = 0.030). No significant difference between groups was recorded for cellular profile and proliferation. CONCLUSION: Patients with Crohn's disease and the NOD2/CARD15 mutation show a remodelling of CLFs in both uninvolved and actively inflamed intestines. These subjects may have a defective immune response by organized lymphoid structures.

The changing impact of age on colorectal cancer surgery. A trend analysis.

OBJECTIVE: The aim of the study was to evaluate the changing influence of age on the outcomes of colorectal cancer surgery in a retrospective trend analysis. METHODS: Data on 985 patients undergoing colorectal cancer surgery were collected during 1975-1984 and 1995-2004. Variables and outcomes of patients aged < 65, 65-74, 75-84 and 85+ years were compared with intra- and interdecade analyses. Endpoints of the study were postoperative mortality, 5-year overall and cancer-related survivals. RESULTS: The rate of elderly patients undergoing colorectal cancer surgery increased significantly from 1975-1984 to 1995-2004. Distribution of American Society of Anesthesiology score and cancer stage remained unchanged over time. The rate of palliative procedures decreased over time, most significantly in the older age groups. In 1995-2004 the palliation rate was similar across all age groups. The rate of emergency surgery also decreased, but it remained higher in older age groups. Operative mortality rate decreased over time across all age groups, but age-related differences were still observed in the 1995-2004 series. Cancer-related survival after curative surgery increased from 58% in 1975-1984 to 64% in 1995-2004 in 75+ years patients, while it increased from 56% to 78% in patients aged 74 years or younger. CONCLUSIONS: Elderly patients with colorectal cancer benefited substantially from healthcare progress during the last 30 years. The reduction of palliative procedures and the decline in operative mortality document the efficacy of not restricting the access to radical surgery for these patients.

Prognostic value of circulating KRAS2 gene mutations in colorectal cancer with distant metastases.

While tissue KRAS2 mutations have been extensively investigated, the role of circulating mutant KRAS2 gene in patients with colorectal carcinoma remains obscure. The aim of the present study was to explore the prognostic significance of circulating KRAS2 gene mutational status in subjects undergoing primary treatment for colorectal cancer. Codon 12 KRAS2 mutations were examined in DNA samples extracted from the serum of 86 patients with colorectal cancer and were compared with the KRAS2 status of their primary tumors. Tissue and serum KRAS2 status was compared with other clinicopathological variables (including CEA and CA 19-9 levels) and with cancer-related survival. KRAS2 mutations were found in tissue samples of 28 patients (33%); serum KRAS2 mutations were detected in 10 of them (36%). Serum KRAS2 status was significantly associated with Dukes' stage D (p=0.001) and with preoperative CA 19-9 levels (p=0.01). At multivariate analysis, cancer-related survival was associated with Dukes' stage (p<0.0001), CEA level (p=0.02), and mutant circulating KRAS2 (p=0.01). All 7 stage D patients with serum KRAS2 mutations died of the disease within 24 months of primary treatment; cancer-related survival was significantly better in 9 stage D patients without serum KRAS2 mutations, with 5 patients (56%) alive after 24 months and 1 patient (13%) alive after 44 months. Residual disease after surgery was evident in all 7 stage D patients with mutant circulating KRAS2, and in 5 out of 9 stage D patients without serum mutations. Serum KRAS2 status may impact substantially on the management of stage D colorectal carcinoma, since it appears to cor-relate with prognosis in this patient subgroup.

Microsatellite instability and mismatch-repair protein expression in hereditary and sporadic colorectal carcinogenesis.

Aberrant crypt foci (ACF) are microscopic clusters of altered colonic crypts considered premalignant lesions in the large bowel. Genomic instability at short tandem repeats in the DNA, referred to as microsatellite instability (MSI) is the hallmark of hereditary nonpolyposis colorectal carcinoma (HNPCC) caused by mutations in DNA mismatch-repair genes, mostly hMLH1 and hMSH2. In this study, we evaluated for MSI ACF (n = 16), adenomas (n = 18), carcinomas (n =22), and lymph node metastases (n = 3) from 17 patients with colorectal cancer positive for MSI. Ten patients were members of HNPCC families; 7 patients had no family history of cancer. MSI was found in 7 of 7 (100%) ACF and 11 of 12 (91%) adenomas from patients with HNPCC. MSI was not related to histology and size of ACF. A progressive increase in instability as estimated by the number of shifted bands was observed along the ACF-adenoma-carcinoma sequence. In contrast, two of nine (22%) ACF and none of six adenomas from patients with MSI sporadic carcinoma were unstable at microsatellite loci. hMLH1 or hMSH2 protein expression was altered only in MSI-positive premalignant lesions (ACF and/or adenomas), but not in all MSI-positive lesions in patients with HNPCC. These observations provide evidence of the premalignant nature of ACF in HNPCC and suggest that MSI is a very early event both in HNPCC and in sporadic colorectal carcinogenesis, although in the latter it seems infrequent.

Four novel MSH2 and MLH1 frameshift mutations and occurrence of a breast cancer phenocopy in hereditary nonpolyposis colorectal cancer.

Hereditary nonpolyposis colorectal cancer (HNPCC) is caused by mutations of genes encoding for proteins of the mismatch repair (MMR) machinery. The majority of mutations occur in the MLH1 and MSH2 genes, and consist of splice-site, frameshift and nonsense changes, leading to loss of protein function. In this study, we screened 7 HNPCC families for MLH1/MSH2 mutations. Sequence changes were identified in 5 families. Four alterations were novel 1- or 2-bp deletions or insertions causing a frameshift and appearance of premature stop codons (MLH1: c.597-598delGA, c.1520-1521insT; MSH2: c.1444delA, c.119delG). The four small insertions/ deletions were located within stretches of simple repeated sequences. By reviewing the HNPCC mutation database, we found that the majority of 1-2 bp frameshift mutations similarly affects simple repetitive stretches, pointing to DNA polymerase slippage during replication as the most likely source of such errors. We also evaluated microsatellite instability (MSI) in a breast carcinoma (BC) from an MLH1 mutation carrier. While a colon cancer from the same individual showed MSI, the BC specimen was MSI-negative, indicating that development of the latter tumor was unrelated to MMR impairment, despite presence of a constitutional MLH1 mutation. Hum Mutat 17:521, 2001.

Aberrant crypt foci in the human colon: frequency and histologic patterns in patients with colorectal cancer or diverticular disease.

Aberrant crypt foci are considered potential markers of colorectal cancer risk. The aim of this study was to analyze a large series of human aberrant crypt foci according to frequency, distribution, and histology. Aberrant crypt foci were identified in methylene blue-stained colonic mucosa from 103 patients undergoing surgery for colorectal cancer or diverticular disease. Foci were histologically classified into surface hyperplastic type, surface and glandular hyperplastic type, mixed hyperplastic and adenomatous type, and adenomatous type. The mean frequency of aberrant crypt foci (n = 720) was higher in the colorectal cancer group (0.20/cm2) than in the diverticular disease group (0.07/cm2), and in distal colonic segments than in proximal segments. Most of the histologically examined foci (n = 366) were hyperplastic (88.8%). Surface hyperplasia accounted for 30.6% and prevailed in small lesions. Surface and glandular hyperplasia accounted for 58.2% and prevailed in medium-sized to large foci. Partially or totally dysplastic foci accounted for 10.1% of examined lesions (10.8% and 2.8% in the colorectal cancer and diverticular disease groups, respectively). Most of them (94.6%) were composed of mixed hyperplastic and adenomatous crypts and prevailed in large lesions. The higher frequency of aberrant crypt foci in patients with colorectal cancer sustains their putative role as preneoplastic markers. The high rate of mixed hyperplastic and adenomatous lesions supports the possible adenomatous transformation of hyperplastic lesions.

Molecular detection of codon 12 K-RAS mutations in circulating DNA from serum of colorectal cancer patients.

Point mutations of the K-RAS gene at codon 12 are found in about 40% of cases with colorectal cancer. The diagnostic implications of the detection of these mutations and their clinical utility are still unclear. The aim of this study was to test both the feasibility of the detection of the mutated K-RAS gene in serum and its potential role in colorectal cancer detection and monitoring. Codon 12 K-RAS mutations were examined in DNA extracted from the serum of 35 patients with colorectal cancer and were compared with the K-RAS status in the corresponding primary tumor. Molecular detection was performed by the mutant-enriched PCR (ME-PCR) assay, a sensitive method capable of distinguishing a small quantity of mutated DNA in the presence of abundant wild-type DNA. The occurrence of mutations was compared with clinicopathological parameters as well as CEA and CA19.9 serum levels. We found codon 12 K-RAS mutations in the tissue of 13/35 (37%) patients. Serum mutations were detected in 5/13 (38.5%) patients with mutated K-RAS in the tissue. 26/35 (74%) patients showed an identical K-RAS pattern in tissue and serum. No codon 12 K-RAS alterations were found in serum samples of 22 patients with benign gastrointestinal diseases. Elevated serum CEA levels were detected in 16 patients, four of whom also presented serum RAS mutations. Our results confirm that K-RAS mutations can be found in circulating DNA extracted from serum samples of patients with colorectal cancer and show that there is a correspondence between serum and tissue K-RAS patterns.

[Severe hypercalcemia due to acute primary hyperparathyroidism: role if parathyroidectomy]. / Ipercalcemia grave da iperparatiroidismo primitivo acuto: ruolo della paratiroidectomia.

Grave hypercalcemia may complicate primary hyperparathyroidism. This clinical condition is potentially life-threatening, if it is untreated. The emergency therapy consist in rehydratation, stimulation of diuresis and somministration of biphosphonates. A urgent surgery is required if conservative therapy is not successful. The Authors herein present a consecutive series of 6 cases with acute hypercalcemic crisis due primary hyperparathyroidism, successful treated with urgent parathyroidectomy after conservative treatment.

[The role of color-Doppler ultrasonography in preoperative study of hyperparathyroidism]. / Ruolo dell'ecocolor-doppler nello studio preoperatorio degli iperparatiroidismi.

The different diagnostic modalities (MIBI scan, ultrasound, CT, MNR) applied in the preoperative study of hyperparathyroidism, have given excellent sensitivity results, only slightly lower than those obtained by surgical exploration performed by experienced surgeons. Yet, their only limitation lies in a lower level of specificity. Other cervical tumours, such as thyroid nodules, lymphoadenopaties, vascular and macular lesions, can in fact be erroneously taken as hyperfunctioning parathyroids. The present paper shows a clinical experience of 27 patients affected by IPT (14 primary IPT, 10 secondary, 3 terziary) who underwent Color-Doppler Ultrasonography and US before surgical exploration. As a result, global sensitivity level reached 81.5%, specificity 100%. In IPT I and III, sensitivity reached 100% while in IPT II it was only 72.2%. In conclusion, Color-Doppler associated with conventional US increases the specificity rate of IPT pre-operative diagnosis.

[Non-polyposis colorectal cancer in subjects under 55 years of age: frequency and phenotype of hereditary or familial syndromes]. / Il cancro non polipotico del colon e del retto sotto i 55 anni di età: frequenza e fenotipo delle sindromi a predisposizione ereditaria o familiare.

Young age is believed to be a risk factor for hereditary or familial non-polyposis colorectal cancer. Present study analysed frequency, phenotype and familial cancer risk of 82 subjects with colorectal cancer under 55 years of age. According to age and family history, probands have been subdivided into 5 groups: Hereditary Non-Polyposis Colorectal Cancer (HNPCC) (8.2% of cases); Suspected HNPCC (7.3%); Non-specific familial aggregation of colorectal cancer (AFACC) (19.5%); Early-onset colorectal cancer (diagnosis under 35 years of age) (CCG) (6.1%); Sporadic colorectal cancer (CCS) (58.5%). Proportions of probands with multiple colonic tumours were highest in HNPCC (57.1%), but present in AFACC (12.5%) and CCG (20.0%) groups, as well. Extracolonic, in particular endometrial and ovarian cancers have been found in HNPCC and AFACC probands. Tumours of proximal colon were most frequent in HNPCC, suspected HNPCC, CCG patients. Eleven-years survival rate was higher in HNPCC probands then in CCS group. Familial cancer risk in HNPCC was 3 times as much as in CCG + CCS groups. Diagnosis of colorectal cancer under 55 years of age is associated with an high frequency of hereditary or familial cases. Genetic tests, surveillance and screening programs in these patients must be based on extensive phenotype and pedigree analyses. HNPCC is widely represented in young colorectal cancer patients and is associated with a high risk of multiple synchronous or metacronous colonic and extracolonic tumours. Total colectomy and eventual hysterectomy with bilateral oophorectomy seem therefore recommendable options in these patients.

[The role of color flow-Doppler ultrasonography in the diagnosis of nodular goiter]. / Ruolo dell'ecocolordoppler nello studio del gozzo nodulare.

Sixtysix patients were submitted to color Doppler ultrasonography, with flowmetric analysis, in the preoperative work up of their thyroid nodules. Three different groups (and two subsets) were so identified, corresponding to the different pathological nodule types: hyperplasia, adenoma, and cancer. The data obtained were then compared to the final pathological results. The color Doppler ultrasonography showed a diagnostic accuracy rate of 87.8%. An evaluation of the peak systolic velocity proved to be very useful in the differential diagnosis between adenomas and cancers. The color Doppler ultrasonography represents a sound method for evaluating thyroid nodules.

[Surgery in severe ulcerative colitis: our experience]. / La chirurgia nella rettocolite ulcerosa grave: nostra esperienza.

BACKGROUND AND AIMS: The mortality in severe episodes of ulcerative colitis (UC) has been reduced from 31-61% in the 1950 to 1-3%. Nevertheless it remains high in non specialist centers. Simple criteria are necessary to predict the outcome of severe ulcerative colitis. METHODS: 14 patients hospitalized for severe disease (Truelove and Witts criteria) from 1996 to 2000 were retrospectively analyzed. Patients were divided into two groups: 1. Group A: patients with severe disease surgically treated. 2. Group B: patients with severe disease responders to medical therapy Sex, age, length of steroids medical therapy, fever, stool frequency, CRP, ESR, haemoglobinemia, leukocytes, serum albumin values in the three days before the operation or during the hospitalization were collected. RESULTS: Total colectomy with ileostomy was necessary in 8 patients (57.1%), while 6 patients (42.90%) were responders to medical therapy. No perioperative mortality was recorded. Stool frequency, CRP, ESR, haemoglobinemia, serum albumin were significantly related to surgical operation. CONCLUSIONS: 1. No uniform criteria off severe attacks, are clearly defined in Literature. 2. The length of pre-operative medical therapy has a tendency to be too high (in our series 19 + 8.2 days). 3. Stool frequency, CRP, ESR, haemoglobinemia, serum albumin were significantly modified in operated patients.

[Course and natural history of idiopathic ulcerative proctitis in adults]. / Decorso e storia naturale della proctite ulcerosa idiopatica nell'adulto.

BACKGROUND AND AIMS: Epidemiological studies have shown that ulcerative proctitis represents 25-55% of ulcerative colitis. In western countries, the incidence of ulcerative proctitis has been increased, while the incidence of more extensive colitis remained unchanged. Compared with extensive ulcerative colitis, the idiopathic proctitis seems to be a benign disease, with an extension to proximal segments in less than 30% of cases, low surgical and cancer risk. On the basis of epidemiological studies, not confirmed by endoscopic and histological features, it has been hypothesized that ulcerative colitis and proctitis could represent two different clinical entities. The aim of the study was to evaluate some clinical and demographic features related to the two different localizations, colitis and proctitis, in the attempt to clarify the above mentioned issues. METHODS: Demographic data of 156 patients observed in our institution from 1982 to 1999, were retrospectively analysed. Diagnosis, extension and severity of ulcerative procto-colitis were based on endoscopic and histological criteria. Local and systemic symptoms, extraintestinal manifestations, surgical and cancer risk, were also recorded. RESULTS AND CONCLUSIONS: Ulcerative proctitis has shown to be a benign disease, with a prevalence of local symptoms, less systemic and extraintestinal manifestations, and low endoscopic grades of activity. Furthermore no surgical intervention and cancer development were recorded. Extension to proximal segments was observed in 10.25% of cases. Young age of onset of symptoms,-smoking and appendectomy were associated to an higher risk of extension of the disease.