Institution of an interdisciplinary IBD centre is associated with improved healthcare utilisation

Despite the institution of an interdisciplinary Inflammatory Bowel Disease (IBD) centre is encouraged, how it may improve patient care is still unknown. In a 5-year period following organisation of an IBD centre, hospitalisations per patient/year decreased (0.41-0.17) and patients on biologics increased (7.7%-26.7%). Total number of hospitalisations (-18.4%) and length of hospitalisation (-29.4%) improved compared with a preceding 5-year period. These findings suggest that institution of an interdisciplinary IBD centre is associated with improved healthcare utilisation.

Single-Port Cholecystectomy for Cholecystitis Versus Non-Cholecystitis

Background and Objectives:

To assess the safety and efficacy of single-port laparoscopic cholecystectomy (SPLC) for the treatment of symptomatic cholelithiasis in different gallbladder pathologic conditions.

Methods:

All patients who underwent SPLC in our department between October 1, 2017 and March 31, 2020 were registered consecutively in a prospective database. Patients’ charts were retrospectively divided according to histological diagnosis: normal gallbladder (NG) (n = 13), chronic cholecystitis (CC) (n =47), and acute cholecystitis (AC) (n = 10). The parameters for assessing the procedure outcome included operative time, blood loss, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and length of hospital stay. Patient groups were statistically compared.

Results:

Seventy patients underwent SPLC. Duration of surgery increased from NG (55 ± 22.7 min) to CC (70 ± 33.5 min), and to AC patients (110.5 ± 50.5 min), which is statistically significant (P = .001). Postoperative complication rates were 7.6% in NG patients, 17% in CC, and 30% in AC (P = .442). Length of hospitalization was shorter for NG patients (1.0 ± 0.6 days) versus CC (2.0 ± 1.1 days) and AC patients (2.0 ± 4.7 days), with statistical significance (P = .020). Multivariate analysis found that pathology type and the occurrence of postoperative complications were independent predictors for prolonged operative times and prolonged hospital stay, respectively.

Conclusion:

SPLC is feasible for acute and chronic cholecystitis with good procedural outcomes. Since SPLC technique itself can be sometimes challenging with the existing technology, its application, especially in cases of acute cholecystitis, should be done with caution. Only prospective randomized studies on this approach for acute and chronic gallbladder diseases will assess the complete reliability of this technique.

OUP accepted manuscript

To date, there are no reports indicating the use of indocyanine green (ICG) fluorescence to detect pathologic lymphatic tissue when a laparoscopic lymph node biopsy (LLB) for suspected new or recurrent lymphoma is performed. We present the case of a 72-year-old female patient admitted for suspicion of recurrent lymphoma. A preoperative imaging work-up showed solid tissue enveloping the terminal portion of the abdominal aorta with a standardized uptake value (SUV) of 10. Therefore, an LLB was planned. After induction of anesthesia, a ICG solution was injected intravenously and subcutaneously at both inguinal regions. At laparoscopy, a complete visualization of the pathologic lymph nodes was achieved, enabling an incisional biopsy of the lymphomatous mass. LLB with ICG-fluorescence offers a simple and safe method for pathologic lymph node detection in the suspicion of intra-abdominal lymphoma. More studies with large case series are needed to confirm the efficacy of this application.

Persistence of Neutralizing Antibodies to SARS-CoV-2 in First Wave Infected Individuals at Ten Months Post-Infection: The UnIRSA Cohort Study

Longitudinal mapping of antibody-based SARS-CoV-2 immunity is critical for public health control of the pandemic and vaccine development. We performed a longitudinal analysis of the antibody-based immune response in a cohort of 100 COVID-19 individuals who were infected during the first wave of infection in northern Italy. The SARS-CoV-2 humoral response was tested using the COVID-SeroIndex, Kantaro Quantitative SARS-CoV-2 IgG Antibody RUO Kit (R&D Systems, Bio-Techne, Minneapolis, USA) and pseudotype-based neutralizing antibody assay. Using sequential serum samples collected from 100 COVID-19 recovered individuals from northern Italy-mostly with mild disease-at 2 and 10 months after their first positive PCR test, we show that 93% of them seroconverted at 2 months, with a geometric mean (GeoMean) half-maximal neutralization titer (NT50) of 387.9. Among the 35 unvaccinated subjects retested at 10 months, 7 resulted seronegative, with an 80% drop in seropositivity, while 28 showed decreased anti-receptor binding domain (RBD) and anti-spike (S) IgG titers, with a GeoMean NT50 neutralization titer dropping to 163.5. As an NT50 > 100 is known to confer protection from SARS-CoV-2 re-infection, our data show that the neutralizing activity elicited by the natural infection has lasted for at least 10 months in a large fraction of subjects.

Single-Port vs. Conventional Multi-Port Laparoscopic Lymph Node Biopsy

Background and Objectives

The purpose of the investigation was to compare clinical results and diagnostic accuracy for conventional multiport laparoscopic lymph node biopsy (MPLB) and single-port laparoscopic lymph node biopsy (SPLB) operations at a single institution.

Methods

A set of 20 SPLB patients operated on from October 2016 to May 2019 were compared to an historical series of 35 MPLB patients. Primary endpoints were the time of surgery, estimated blood loss, surgical conversion, length of stay and morbidity. The secondary endpoint was the diagnostic accuracy of the technique.

Results

SPLB was completed laparoscopically in all cases. Two MPLB patients (5.7%) experienced a surgical conversion due to intraoperative difficulties. Duration of surgery was similar in SPLB and MPLB groups respectively (84 ± 31.7 min vs. 81.1 ± 22.2; P = .455). A shorter duration of hospital stay was shown for patients operated on by SPLB compared to the MPLB group (1.7 ± 0.9 days vs. 2.1 ± 1.2 days; P = .133). The postoperative course was uneventful in both groups. In 95% of the SPLB and 97.1% of the MPLB cases respectively, LLB achieved the necessary information for the diagnosis.

Conclusion

SPLB has shown good procedural and postoperative outcomes as well as a high diagnostic yield, comparable to traditional MPLB. Therefore, our results show that this approach is safe and effective and can be an equally valid option to MPLB to obtain a diagnosis or to follow the progression of a lymphoproliferative disease. Further studies are necessary to support these results before its widespread adoption.

Stress levels among workers: an observational study

Introduction

While some stress is a common part of everyday work for most people, higher or prolonged levels of stress might be harmful. Work-related stress is becoming a study subject because of its important implications: it is related to coronary heart disease and health in general and it also influences employee satisfaction and productivity. Because of this, workers should be aware of their stress levels in order to prevent disease and increase performance levels. Therefore, the aim of our study was to evaluate stress levels among employees.

Methods

We conducted an observational study in collaboration with Anteo, an onlus society based in Biella which employs more than 1000 workers. The first step of our study ran from December 2019 to February 2020, and included 300 workers. Informed consent was gathered trough structure chiefs prior to the intervention. We administered an online questionnaire based on the Kessler Psychological Distress Scale (K10) for screening than, subjects with a high perceived stress level were invited for a personal interview with our medical and psychological staff.

Results

The response rate was 31% with 94 questionnaires completed by the end of February 2020. 80% of respondents were women (75 out of 94). 17% of the employees presented a moderate to high level of stress (16 total, 72% women). Only 5% of workers presented a high level of stress (4 total, 50% women). All Patients presenting a high level of perceived stress went through medical and psychological evaluation, which confirmed the results in 88% cases (14 out of 16).

Conclusions

Our study evidenced that workers are often exposed to high levels of stress, which can influence health, everyday life as well as productivity. The introduction of stress management programs in companies could improve workers health and productivity having a positive impact on one's health, company productivity and society in general.

Key messages

The introduction of stress management programs might improve workers health and productivity. The introduction of stress management programs might have a positive impact on one’s health, company productivity and society in general.

SECCA procedure for anal incontinence and antibiotic treatment: a case report of anal abscess

Background

Fecal Incontinence (FI) can seriously affect quality of life. The treatment of fecal incontinence starts conservatively but in case of failure, different surgical approaches may be proposed to the patient. Recently several not invasive approaches have been developed. One of these is the radiofrequency (RF) energy application to the internal anal sphincter.

Case presentation

We report a rare case of an anal abscess related to a SECCA procedure in a 66-year-old woman affected by gas and FI for twenty years.

Conclusions

The complications post-SECCA procedure reported in literature are generally not serious and often self-limited, such as bleeding or anal pain. This is a case of an anal abscess.

We suggest that this finding could consolidate the importance of administering antibiotic therapy to patients and to run a full course of at least 6 days rather than a short-term (24 h) therapy, with the aim to minimize the incidence of this complication.

Carcinosarcoma of the Lung: A Case Report

The clinical and pathological data of a single case of carcinosarcoma of the lung observed in the period from 1978 to 1998 were reviewed. The diagnosis was based on immunohistochemical examination of the surgical specimen after a lower left lobectomy. The patient was given adjuvant chemotherapy. The local recurrence showed only sarcomatous features. The characteristics of this rare tumor are discussed in this case report.

Radiofrequency Procedure (SECCA®) for Fecal Incontinence: One-Year Experience

INTRODUCTION

Radiofrequency is a treatment option for patients suffering from fecal incontinence.

OBJECTIVE

To assess the one-year follow-up results following the radiofrequency procedure for fecal incontinence.

DESIGN

Prospective, single-center, observational study.

MATERIALS AND METHODS

Twenty-one patients underwent the SECCA® radiofrequency procedure, 19 of who completed the one-year of follow-up (Cleveland Clinic Florida Fecal Incontinence score, Fecal Incontinence Quality of Life Scale (FIQoL), anorectal manometry, and endoanal ultrasound).

MAIN OUTCOME MEASURES

Any change in the Fecal Incontinence Score or Fecal Incontinence Quality of Life scales post SECCA® radiofrequency procedure.

RESULTS

The mean Fecal Incontinence Score significantly improved at three months' follow-up from 14.5 prior to treatment to 11.9 post-treatment, and was maintained at six months (12). A slight decrease was observed at one year (12.9), which had no impact on the global satisfaction. During the same period, only 1/4 subsets of the Fecal Incontinence Quality of Life score improved. Manometry and endoanal ultrasound did not show significant changes post procedure.

LIMITATIONS

Limited number of patients.

CONCLUSIONS

Radiofrequency is a valid treatment option for patients with mild-to-moderate fecal incontinence. This treatment has demonstrated clinically significant improvements in symptoms, as demonstrated by statistically significant reductions in the Fecal Incontinence Score as well as significant improvements in Fecal Incontinence Quality of Life scores at six months, with a slight, though not clinically significant, decrease at one year follow-up.

Immunoglobulin-A Profile in Breast Milk from Mothers Delivering Full Term and Preterm Infants

Recent advances in the care of low-birth-weight and preterm neonates have stimulated research into the best dietetic program to improve their survival and short/long term outcome. Some components of human milk that cannot be included in artificial formulas may be critical for survival. Of these, immunoglobulins are important, and in particular secretory immunoglobulins A (sIgA). The concentration of secretory IgA was measured by immunoblotting (an immunoelectrophoretic technique having high specificity and reliability) in milk from mothers delivering at term (TM) or prematurely (PM). In both groups, IgA concentrations were high very early on but quickly decreased during the first week of lactation. The early IgA mean concentration was higher in PM than in TM but, because of high variability in PM milk, the difference rarely reached statistical significance. This variability during lactation reflects the important role of human milk in supplying immunological factors to cope with the gastrointestinal absorption of high molecular weight proteins in the first days of life. Immunological protection is particularly critical for a preterm baby, so it is important to promote feeding with its own mother's milk if possible, paying strict attention to the timing of milk collection.

Congenital internal hernia through defect in the falciform ligament in adult: A case report and review of the literature

INTRODUCTION

The incidence of occlusion syndrome caused by internal hernia is very rare, in particular when the defect is congenital discovered in adults with no previous abdominal surgery.

PRESENTATION OF CASE

We present a case of a 31 year-old female patient who presented with acute abdominal pain and mechanical obstruction. The patient had never undergone abdominal surgery.

DISCUSSION

On diagnostic laparoscopy, it was found a herniation of a loop of small bowel through a hole in the falciform ligament. The obstruction was solved by the division of part of falciform ligament without intestinal resection.

CONCLUSION

Internal hernia is a very uncommon pathology, most often discovered in pediatric age because of congenital abnormalities, it must be included in the differential diagnosis in adults. Preoperative diagnosis is difficult. The diagnostic laparoscopic approach has shown to be the best.

Stapled Mesh Reinforcement Technique (SMART) to Prevent Parastomal Hernias: Our Initial Experience and Review of the Literature

Parastomal hernia is one of the most common stoma related complication, with the correlated risk of incarceration, obstruction, and strangulation. The incidence is high (30-50%) and depends on the length of follow up. Different surgical options for repairing are defective with a 25-70% failure and recurrence rate. Prevention of parastomal hernia with mesh reinforcement seems to be effective. Three available trials are recruiting patients: Prism (with matrix porcine prothesis), Prevent (with preperitoneal polypropylene mesh), and the stapled polypropylene mesh stoma reinforcement technique (SMART). We performed the SMART procedure in six patients undergoing definitive colostomy. Our cases show that the procedure is rapid (duration range 15-20 minutes), cost effective (500 euro), and safe (in our experience, there are no post-surgical complications that are procedure-related). A long term follow-up and a higher number of patients will give us confirmation of the initial hopeful results.

Splenectomy for E. coli abscess: A case report with a difficult preoperative diagnosis and unclear pathogenesis

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Difficult diagnosis due to the paucity of symptoms and atypical radiological findings.

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Primary site of infection was not detected.

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Splenectomy is the best therapeutic choice in case of splenic abscess.

Introduction

Isolated splenic abscess is a rare clinical condition and remains a diagnostic dilemma. Clinical presentation is non-specific and the diagnosis is often delayed. Ultrasonography and CT scan are the gold standard. The treatment is still controversial: antibiotic therapy, percutaneous drainage (PCD) or splenectomy.

Case presentation

We present the clinical case of a patient, admitted to our Department because of abdominal pain, without fever. The preoperative radiological assesment showed three intrasplenic liquid collections, whose differential diagnosis was made between hematic collection and abscess. The treatment was splenectomy. The samples of collected liquid were positive for Escherichia Coli.

Conclusion

In case of splenic abscess, splenectomy is the best therapeutic choice. The other therapeutical options like antibiotic therapy and PCD, can be used only in particular cases, but without the same efficacy.

Molecular detection and isolation of West Nile virus from a human case in northern Greece, 2013

In order to laboratory confirm the first suspected West Nile fever case in 2013 in northern Greece, a combination of serological molecular and culture methods were applied. It was shown that the causative West Nile virus strain belonged to lineage 2, and possessed the amino acid substitution H249P in the NS3 protein, as in previous years. The significance of this specific strain in Europe remains to be elucidated.

Laparoscopic bridging vs. anatomic open reconstruction for midline abdominal hernia mesh repair [LABOR]: single-blinded, multicenter, randomized, controlled trial on long-term functional results

BACKGROUND

Re-approximation of the rectal muscles along the midline is recommended by some groups as a rule for incisional and ventral hernia repairs. The introduction of laparoscopic repair has generated a debate because it is not aimed at restoring abdominal wall integrity but instead aims just to bridge the defect. Whether restoration of the abdominal integrity has a real impact on patient mobility is questionable, and the available literature provides no definitive answer. The present study aims to compare the functional results of laparoscopic bridging with those of re-approximation of the rectal muscle in the midline as a mesh repair for ventral and incisional abdominal defect through an "open" access. We hypothesized that, for the type of defect suitable for a laparoscopic bridging, the effect of an anatomical reconstruction is near negligible, thus not a fixed rule.

METHODS AND DESIGN

The LABOR trial is a multicenter, prospective, two-arm, single-blinded, randomized trial. Patients of more than 60 years of age with a defect of less than 10 cm at its greatest diameter will be randomly submitted to open Rives or laparoscopic defect repair. All the participating patients will have a preoperative evaluation of their abdominal wall strength and mobility along with volumetry, respiratory function test, intraabdominal pressure and quality of life assessment.The primary outcome will be the difference in abdominal wall strength as measured by a double leg-lowering test performed at 12 months postoperatively. The secondary outcomes will be the rate of recurrence and changes in baseline abdominal mobility, respiratory function tests, intraabdominal pressure, CT volumetry and quality of life at 6 and 12 months postoperatively.

DISCUSSION

The study will help to define the most suitable treatment for small-medium incisional and primary hernias in patients older than 60 years. Given a similar mid-term recurrence rate in both groups, if the trial shows no differences among treatments (acceptance of the null-hypothesis), then the choice of whether to submit a patient to one intervention will be made on the basis of cost and the surgeon's experience.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN93729016.

Technological improvements in the treatment of haemorrhoids and obstructed defaecation syndrome

BACKGROUND

An evolution of CPH34 (CPH34 HV) for stapled transanal rectal resections was developed and tested to assess its safety and resection volume as compared to other staplers.

MATERIALS AND METHODS

A total of 16 pigs were randomly assigned to rectal prolapsectomy with CPH34 HV (n=4), CPH34 (n=4), PPH03-33 (n=4), HEEA (n=2) and PPH-01 (n=2). Measures and histological structure of specimens were assessed; transrectal echotomography (ETG) was performed on the third postoperative day, hence pigs were autopsied.

RESULTS

Significant differences of the volumes and weights of specimens were observed by type of stapler (p=0.0298 and p=0.0278, respectively) which were mainly due to CPH34 HV vs. PPH03-33 (p=0.0402 and p=0.0375, respectively). The average volumes were 17.1% lower for CPH34, 30.2% lower for HEEA, and 34.7% lower for PPH03-33 with respect to CPH34 HV. No significant increase of resection volume (7.5%) was observed between two PPH-01 units combined (two specimens together) vs. a single CPH34 HV unit. The highest percentage of muscularis propria was observed into the specimens collected with CPH34 HV and HEEA (50%). ETG detected three intra- and two extraparietal haematomata.

CONCLUSION

The safety and higher volume of resection achievable with CPH34 HV correlated well with the specimen weight and percentage of muscularis propria.

Tension-free primary closure with autologous platelet gel versus Vivostat- for the definitive treatment of chronic sacrococcygeal pilonidal disease

OBJECTIVE

A randomized clinical trial was performed in patients with chronic or recurrent pilonidal sinus (PS) comparing primary closure coupled with random application of in house autologous platelet gel or produced by means of Vivostat- in order to assess whether a standardized product had an impact on the wound healing process.

PATIENTS AND METHODS

Between June 2006 and June 2009, 100 patients (82 males, 18 females: median age 30 years; range, 16-51 years) underwent wide excision of the pilonidal area with midline tension-free closure and were randomly given either the in house autologous platelet gel (Group 1) or the Vivostat- gel (Group 2).

RESULTS

Group 2 patients had shorter wound healing time (8 vs. 10 days; p<0.0001), time to return to full activity (11 vs. 16 days: p<0.0001), less uncomplicated fluid collections (120 vs. 190 ml: p<0.0001), and fewer postoperative wound complications (1/50=2% vs. 5/50=10%, p<0.001). After a median follow-up of 21 months (range: 4-40 months), two recurrences were detected in Group 1.

CONCLUSION

The standardized production of platelet gel by means of the Vivostat- system guarantees the reproducibility of the procedure and its use was correlated with an improved outcome, with a high degree of patient satisfaction and better cosmetic results.

alpha1-Acid glycoprotein production in rat dorsal air pouch in response to inflammatory stimuli, dexamethasone and honey bee venom

This study shows the rapid and differential production of the 40-43 kDa and the 70-90 kDa alpha1-acid glycoprotein (AGP) fucosylated glycoforms after treatment of the dorsal air pouch with bacterial lipopolysaccharide (LPS), HgCl(2) or Freund's complete adjuvant (FCA). The 40-43 kDa and the 70-90 kDa AGP production is peaked 1-3 h post-LPS treatment. We observed that the responses to LPS and FCA are similar in that both AGP isoforms are induced whereas they differ in that the FCA exhibits a 6 h lag period. The response to HgCl(2,) however, exhibits the specific biphasic induction only of the 40-43 kDa AGP. The serum 40-43 kDa AGP glycoform gradually increases in response to all of the above stimulants and peaks by 24 h post- treatment. The increase of the 70-90 kDa AGP levels in the air pouch occurs in association with the accumulation of polymorphonuclear (PMN) cells while dexamethasone (DEX) increases only the 40-43 kDa AGP production in the absence of PMN accumulation. Macrophage-monocyte lineage cells forming the air pouch lining tissue may potentially be the cells that secrete the 40-43 kDa AGP while polymorphonuclear cells that infiltrate the air pouch secrete the 70-90 kDa AGP. The 40-43 kDa and 70-90 kDa AGP production induced by LPS in the air pouch precedes that of interleukin-1 (IL-1) or interleukin-6 (IL-6) while the 40-43 kDa AGP glycoform potentially increases IL-6 production by air pouch PMN exudate cells. These significant differences suggest a local pro-inflammatory role of AGP. Honeybee venom suppressed arthritis development and exhibited differential local or systemic regulation of AGP in serum vs. air pouch exudate or synovial fluid. This study with the air pouch model of facsimile synovium tissue suggests that local alpha1-acid glycoprotein (AGP) production may contribute to pro-inflammatory and anti-inflammatory activities during the local acute phase response or during chronic inflammatory stress as in arthritis.

Proteolysis of Milk Fat Globule Membrane Proteins in Preterm Milk: A Transient Phenomenon with a Possible Biological Role?

Milk fat globule membrane (MFGM) proteins constitute a milk fraction currently of great interest, as they appear to significantly contribute to milk protective role. We investigated these proteins in human preterm colostrum and milk. For the former we found a peculiar 2-DE pattern, with a spot concentration at low molecular weight, which mass spectrometry analysis showed to be fragments belonging to some MFGM proteins with a well-known biological and especially immunological role: lactadherin, membrane-associated lactoferrin, butyrophilin, clusterin and heavy-chain immunoglobulin. Since we were able to rule out protease activity after specimen collection, we hypothesize the localization of the proteolytic enzymes in the alveolar cell membranes of the mammary gland. This mechanism is probably under hormonal control and the unexpected advent of preterm delivery would not allow hormonal conditions typical of lactation to occur immediately, causing a delay in enzymatic inhibition. This hypothesis is supported by some of our results, picturing a peculiar transient phenomenon of adaptation of the mammary-gland-membrane proteins after preterm delivery. Further studies will be required to verify whether the presence of protein fragments exerts a specific biological and immuno-defensive role in preterm infants, thus adding evidence to the outstanding biological role and benefits of mother's own milk in feeding preterm infants.

Effects of Holder pasteurization on human milk oligosaccharides

The benefits of human milk have been confirmed for preterm infants, due to its nutritional aspects and to its biologically active compounds. Oligosaccharides play an emerging leading role among these compounds. Mother's milk can sometimes be lacking for preterm infants; pasteurized donor milk represents therefore an important alternative. The aim of this study is to evaluate the effects of Holder pasteurization on the concentration and pattern of oligosaccharides in preterm human milk. Our results indicate that pasteurization does not affect the concentration or pattern of analyzed oligosaccharides.

Regenerative medicine for the definitive surgical repair of pilonidal sinus. A new method of wound reconstruction

OBJECTIVE

A retrospective analysis of patients undergoing surgery for complex (> or =3 tracks) or recurrent pilonidal sinus (PS) was performed; the results of this clinical experience were compared with an original method of primary wound closure, coupling a "tension-free" technique of wound reconstruction with autologous cryoplatelet gel application, in order to improve the wound healing process and reduce the postoperative disability period.

PATIENTS AND METHODS

The retrospective analysis included 30 patients undergoing surgery for PS between January 2003 and May 2005: in the first group of 15 consecutive patients, the wound was left open to close secondarily while in the remaining 15 patients, primary closure by means of a "tension-free" technique of wound reconstruction was attempted. Between June 2005 and May 2006, another subset of 15 patients was prospectively recruited, coupling the "tension-free" technique of wound reconstruction with autologous cryoplatelet gel application.

RESULTS

In the first group of patients, median postoperative disability accounted for 65 days with one recurrence. In the second group, primary healing was achieved in 11 patients, with a median postoperative disability of 28 days; two recurrences did occur. In the third group of patients, primary healing was achieved in all patients within 14 to 29 days, and no recurrence has yet been detected.

CONCLUSION

Short follow-up notwithstanding, the simplicity of the operation, the use of autologous products and the minimal postoperative disability with complete wound healing suggest that this new approach may represent a useful alternative to current surgical techniques for PS excision.

The rabbit motilin receptor: molecular characterisation and pharmacology

Following identification of the human motilin receptor, we isolated the rabbit orthologue by PCR amplification and found this to be 85% identical to the open reading frame of the human receptor. The protein encoded was 84% identical to the human polypeptide. In HEK293T cells transfected with the rabbit receptor, motilin concentration-dependently increased intracellular calcium mobilisation (pEC50=9.25). After transfection with Go1alpha, motilin similarly stimulated [35S]GTPgammaS binding (pEC50=8.87). Using both systems, similar values were obtained with the human receptor, with rank-order potencies of motilin=[Nle13]-motilin>erythromycin; ghrelin was ineffective. In circular muscle preparations of rabbit gastric antrum, [Nle13]-motilin 0.1-30 nM concentration-dependently increased the amplitude of electrically-evoked, neuronally-mediated contractions (pEC50=8.3); higher concentrations increased the muscle tension (30-3000 nM). Both responses to [Nle13]-motilin faded rapidly during its continual presence. Rat or human ghrelin 0.01-10 microM were without activity. Erythromycin 30-3000 nM and 10 microM, respectively, increased neuronal activity and muscle tension in rabbit stomach. Unlike [Nle13]-motilin, the increase in neuronal activity did not fade during continual presence of submaximally-effective concentrations of erythromycin; some fade was observed at higher concentrations. We conclude that the pharmacology of the rabbit motilin receptor is similar to the human orthologue and, when expressed as a recombinant, comparable to the native receptor. However, in terms of their ability to increase neuronal activity in rabbit stomach, [Nle13]-motilin and erythromycin are distinguished by different response kinetics, reflecting different rates of ligand degradation and/or interaction with the receptor.

[Robotic and systems technology for advanced endoscopic procedures]

The advent of endoscopic techniques changed surgery in many regards. This paper intends to describe an overview about technologies to facilitate endoscopic surgery. The systems described have been developed for the use in general surgery, but an easy application also in other fields of endoscopic surgery seems realistic. The introduction of system technology and robotic technology enables today to design a highly ergonomic solo-surgery platform. This consists of a system of devices for endoscopic surgery (HF, light source, etc...) with which the surgeon interacts directly, positioning systems for optic and instruments that the surgeon drives as the likes without assistance, and a chair to increase the comfort of the surgeon during surgery. The system of endoscopic devices named OREST (Dornier, München) designed already in 1992 opened the way to a number of systems available today that allow to the surgeon a direct control of the instrumentation. A considerable step ahead in endoscopic technology is the introduction of robotic technology to design assisting systems for solo-surgery and microsurgical instrument manipulators. Results of a number of experimental trials on combinations of different positioning devices are presented and commented. A further step in the employment of robotic technology is the design of "master-slave manipulators" to provide the surgeon with additional degrees of freedom of instrumentation. In 1996 a first prototype of an endoscopic manipulator system, named ARTEMIS, designed in cooperation with the Research Center in Karlsruhe, could be used in experimental applications. Clinical use of the system, however, will require further development of the arm mechanics and the control system. The combination with the implementation of telecommunication technology will open new frontiers, such as teleconsulting, teleassistance and telemanipulation.

The human GABA(B1b) and GABA(B2) heterodimeric recombinant receptor shows low sensitivity to phaclofen and saclofen

1. The aim of this study was to characterize the pharmacological profile of the GABA(B1)/GABA(B2) heterodimeric receptor expressed in Chinese hamster ovary (CHO) cells. We have compared receptor binding affinity and functional activity for a series of agonists and antagonists. 2. The chimeric G-protein, G(qi5), was used to couple receptor activation to increases in intracellular calcium for functional studies on the Fluorimetric Imaging Plate Reader (FLIPR), using a stable GABA(B1)/GABA(B2)/G(qi5) CHO cell line. [(3)H]-CGP-54626 was used in radioligand binding studies in membranes prepared from the same cell line. 3. The pharmacological profile of the recombinant GABA(B1/B2) receptor was consistent with that of native GABA(B) receptors in that it was activated by GABA and baclofen and inhibited by CGP-54626A and SCH 50911. 4. Unlike native receptors, the GABA(B1)/GABA(B2)/G(qi5) response was not inhibited by high microMolar concentration of phaclofen, saclofen or CGP 35348. 5. This raises the possibility that the GABA(B1)/GABA(B2)/G(qi5) recombinant receptor may represent the previously described GABA(B) receptor subtype which is relatively resistant to inhibition by phaclofen.

[Positioning systems for endoscopic solo surgery]

BACKGROUND

Endoscopic surgery has acquired undisputed importance in the field of both general and specialised surgery. The introduction of robotic technology in surgery has recently led to the development of new positioning systems for endoscopic surgery. These allow direct control of the endoscopic procedures by the surgeon, whose vision currently depends on the assistant in charge of positioning the optic camera in compliance with his wishes.

METHODS

We experimented different positioning systems for optics and rigid endoscopic instruments for laparoscopy, some of which were our own design. Over 400 cholecystectomies were carried out by six different surgeons on phantoms containing animal organs. The experimental systems were AESOP (Computer Motion, USA), with both foot-pedal and voice control, ENDOASSIST (Armstrong Healthcare Co. UK), controlled by a device worn by the surgeon, FIPS Endoarm (Karlsruhe Research Centre, Germany), controlled by a joystick and voice, and the passive TISKA Endoarm system (Karlsruhe Research Centre, Germany). Combinations of two systems were compared, using one to position the optic and one to position the retractor instrument.

RESULTS

Phantom tests, which are preferable owing to constant conditions, showed the feasibility of experiments in Solo Surgery conditions and highlighted the advantages and drawbacks of the various systems. In particular, the surgeons appreciated the intuitive use of the TISKA Endoarm system as a positioner for the retractor instrument and the optics, in spite of the fact that it was only a passive movement apparatus. Among the remote-control systems tested as an optics positioner, FIPS Endoarm controlled by a joystick was particularly intuitive and produced the best results in terms of time taken to complete the procedure. The time taken was even shorter than that in a large control group with human assistance.

CONCLUSIONS

In our experience endoscopic Solo Surgery was found to be applicable to clinical practice. This will bring numerous advantages in terms of the precision of surgical procedures and savings in terms of time and human resources, with a consequent reduction of management costs. There is no doubt that this method represents a step forward in the application of technology to surgery.

A new remote-controlled endoscope positioning system for endoscopic solo surgery. The FIPS endoarm

In the field of endoscopic solo surgery, the assistance received by the surgeon from ergonomical positioning devices is extremely important. They aid in both the retracting of instruments and the positioning of the endoscope. However, passive systems derived from open surgery have not proved satisfactory. Therefore, we set out to develop a remote-controlled arm capable of moving a rigid endoscope with about four degrees of freedom, while maintaining an invariant point of constraint motion coincident with the trocar puncture site through the abdominal wall. The system is driven by means of speaker-independent voice control or a finger-ring joystick clipped onto the instrument shaft close to the handle. When the joystick is used, the motion of the endoscope is controlled by the fingertip of the operating surgeon, which is inserted into the small ring of the controller in such a way as to make the motion of the fingertip correspond directly to the motion of the tip of the endoscope. A study was performed to compare the two different interfaces available for the system. With both interfaces, the guiding system allows for transparent and intuitive operation. Its set-up is easy; it is safe and reliable to use during the intervention; and it is faster than human assistance. With its improved ergonomy, this new generation of remote-controlled endoscope positioning system represents a further step toward the diffusion of solo surgery techniques in minimally invasive therapy. In our opinion, this prototype creates a valid compromise between human and robotic control of rigid endoscopes.

The "Will Rogers effect" on stage grading

Will Rogers phenomenon affects survival statistics applied to clinical research and could determine a misreading of results. Stage migration due to new methods of diagnostic imaging and staging invasive procedures could improve actuarial survival in each stage. TNM System is impaired when survival rates come from different inhomogeneous countries, regions and eras. Randomized trials suffer this fallacious phenomenon when staging depends on the different treatments which are to be evaluated.

The new international staging system for lung cancer. Evolution of the system and concerned remarks

The rationale of the Staging System of Lung Cancer is discussed from his presentation (Mountain, 1985) to the recent revision and proposals of new classifications. Survival rates offered a strong statistical support to the latest revision in 1997. Stage Group have become 7 out of Stage 0 (Tis). In the New Lymph Node Map, station 4 is confirmed as mediastinal (N2). The improved definition of Stage Grouping requires a golden standard of staging and a worldwide consensus on the surgical approach to mediastinal lymphadenectomy. IASLC, the International Association for the Study of Lung Cancer, is now moving to collect a new largest database with the aim to offer the next expected Revision.

Considerations about tumor size as a factor of prognosis in NSCLC

A literature review of the initial attempt to correlate tumor size in NSCLC with the expectancy of survival is presented starting from the 60s. The larger size was connected with an increased risk of metastatic diffusion. In the 70s resulted evident the relationship between tumor size and lymph node involvement so affecting survival. In the context of the TNM Staging System (Mountain 1986) size appeared a well assessed factor of prognosis and is recognised to play a major role in Stage I where the subsets T1N0 and T2N0 showed a consistent difference in survival across the 3 cm cut-off. The peculiar relation between largest size and mediastinal lymph node metastases is discussed as well as the proposal to allocate T2 descriptor within the range 3-5 cm. Finally, series of clinical observations from Japanese experience about small sized T1N0 tumors are presented and discussed.

The invasive staging and the role of complete resection in the surgical treatment of NSCLC

Years of debates couldn't solve the discussion between the NSCLC assessment founded on CT scan and mediastinoscopy as in the Western countries and the refined extensive bronchoscopy, CT imaging and exploratory thoracotomy as practiced in Japan. Recently, the clinical onset of combined therapy protocols, the recognised value of the intrathoracic staging (also in the West) and survival rates in the earlier N2 disease moved towards change this steady situation. The role of complete resection in N2 NSCLC is therefore debated from the preoperative assessment to survival results in resected cases. Accuracy of CT scan and cervical mediastinoscopy is discussed also in the light of neoadjuvant therapy. The clinical value of intrathoracic staging is improved by Japanese experiences while a rationale assessment of Complete/Incomplete Resections is defined. Moreover, technical details of intraoperative recognition are cleared.

Molecular and pharmacological characterization of a functional tachykinin NK3 receptor cloned from the rabbit iris sphincter muscle

1. A functional tachykinin NK3 receptor was cloned from the rabbit iris sphincter muscle and its distribution investigated in ocular tissues. 2. Standard polymerase chain reaction (PCR) techniques were used to clone a full length rabbit NK3 receptor cDNA consisting of 1404 nucleotides. This cDNA encoded a protein of 467 amino acids with 91 and 87% homology to the human and rat NK3 receptors respectively. 3. In CHO-K1 cells transiently expressing the recombinant rabbit NK3 receptor, the relative order of potency of NKB>>NKA>/=SP to displace [125I]-[MePhe7]-NKB binding and to increase intracellular calcium, together with the high affinity of NK3 selective agonists (e.g. senktide, [MePhe7]-NKB) and antagonists (e.g. SR 142801, SB 223412) in both assays was consistent with NK3 receptor pharmacology. In binding and functional experiments, agonist concentration response curves were shallow (0.7 - 0.8), suggesting the possibility of multiple affinity states of the receptor. 4. Quantitative real time PCR analysis revealed highest expression of rabbit NK3 receptor mRNA in iris sphincter muscle, lower expression in retina and iris dilator muscle, and no expression in lens and cornea. In situ hybridization histochemistry revealed discrete specific localization of NK3 receptor mRNA in the iris muscle and associated ciliary processes. Discrete specific labelling of NK3 receptors with the selective NK3 receptor agonist [125I]-[MePhe7]-NKB was also observed in the ciliary processes using autoradiography. 5. Our study reveals a high molecular similarity between rabbit and human NK3 receptor mRNAs, as predicted from previous pharmacological studies, and provide the first evidence that NK3 receptors are precisely located on ciliary processes in the rabbit eye. In addition, there could be two affinity states of the receptor which may correspond to the typical and 'atypical' NK3 receptor subtypes previously reported.

Transcellular metabolism of leukotriene A4 by rabbit blood cells: lack of relevant LTC4-synthase activity in rabbit platelets

The objective of this study was to determine the transcellular metabolism of leukotriene A4 by rabbit blood cells. mixed peripheral blood leukocyte preparations with and without platelets in a ratio of 1:40 were challenged with the Ca(2+)-ionophore A23187. 5-Lipoxygenase metabolites production was assessed by RP-HPLC coupled with diode-array UV detection. In light of the observation that leukotriene C4 production in leukocyte-platelet coincubation was the same as with leukocytes alone, mixed coincubation of human and rabbit blood cells was tested. Rabbit leukocytes with human platelets resulted in a significant increase of leukotriene C4 production, while no changes were observed in human leukocytes with or without rabbit platelets. In agreement with these results, intact rabbit platelets or rabbit platelet lysates, unlike human platelets, were not able to convert synthetic leukotriene A4 free acid to leukotriene C4. These data provide evidence that rabbit leukocytes are able to make a significant amount of leukotriene A4 available for transcellular metabolism, while rabbit platelets, unlike human platelets, lack leukotriene C4-synthase activity.

Consensus on diuresis renography for investigating the dilated upper urinary tract. Radionuclides in Nephrourology Group. Consensus Committee on Diuresis Renography

There is great variation in technique and interpretation of diuresis renography between different establishments.

METHODS

To address this problem, an International Consensus Committee was appointed by the Ninth International Symposium on Radionuclides in Nephrourology in 1994.

RESULTS

The final document was produced and addressed: objectives, equipment, data acquisition, choice of radiopharmaceutical, patient preparation, position, dosage of furosemide, timing of furosemide, role of bladder catheter, duration of study, pediatric considerations, evaluation of the furosemide response, interpretation, and conclusion.

CONCLUSION

The report presents a standardized approach to diuresis renography that, if adopted, will improve reproducibility between centers, discourage unacceptable practice and stimulate further discussion between nuclear medicine and urology health care professionals who treat patients with dilated and obstructed upper urinary tracts.

[Adrenalectomy in metastasis of primary pulmonary carcinoma: an emerging issue]

Such a novel surgical project is supported by a large basic knowledge on molecular biology of solid tumours progression as well as the already assessed clinical experience in the parallel field of surgery for lung, brain and liver metastases. While pathology and the clinical work up have for a long time pointed out the steady rate of adrenal metastatic involvement from lung cancer (from 25 to 28% of all cases at the autopsy and, on clinical grounds, the most important site of extrapulmonary tumour spread just after the first one represented by the mediastinal lymphatic groups), the surgical approach to the problem is still very limited and the few operated cases previously reported in world literature (summing up to a total of 21) are not truly homogeneous and even largely scattered in time. The Authors report on their personal contribution in this field with four consecutive cases who underwent surgery during the last five years. The most important clinical features together with the initial remarkable result obtained in one patient who is still free of disease more than 3 years after the sequential radical resection of the primary lung tumour and the metastatic ipsilateral adrenal gland, are presented. In the light of this preliminary positive experience, the Authors are planning a sound clinical research based on the combined resection of those NSC Lung Cancers which appear surgically resectable but already included in an unresectable Stage IV Disease only because of the contemporary adrenal metastases (M1). An adjuvant chemotherapy in usually added.

Leukotriene A4, and not leukotriene B4, is the main 5-lipoxygenase metabolite released by bovine leukocytes

The production of leukotriene A4 (LTA4)-derived metabolites, analysed by RP-HPLC, was studied in purified bovine polymorphonuclear leukocyte (PMNL) preparations and in PMNL-platelet coincubations after challenge with the calcium ionophore A23187. The results obtained show that in bovine PMNL LTB4 represents the main LTA4 metabolite. When washed platelets were added to PMNL, LTC4 was the main enzymatic metabolite observed, indicating a substantial transfer of PMNL-derived LTA4 to platelets. The synthesis of LTC4 was accompanied by a significant decrease in LTB4, suggesting that a quota of the LTB4 synthesized in PMNL preparations is the result of transcellular metabolism of released LTA4 by neighbouring PMNL. Reduction of PMNL-PMNL interactions through dilution of cell incubates allowed us to estimate that most of the leukotriene A4 synthesized by PMNL is indeed released from the cell. LTA4, and not LTB4, represents the main 5-lipoxygenase metabolite released by bovine PMNL.

Resection for peripheral higher stage lung tumor. A compared Italian cumulative experience

Preceded by an international overview on the surgical approach to the peripheral higher stage NSCLC, the cumulative clinical experience from ten Italian University Departments and Teaching Hospitals, is analyzed in the light of the corresponding international contributions. Accordingly, the clinical records of 470 patients affected by such Stage III tumors and surgically treated, were collected and retrospectively reviewed. 43 out of 120 patients belonging to the group of apical invasive Pancoast's tumour underwent an en-bloc chest-wall resection, while an extrapleural dissection was performed in the remaining 77. Combined segmentectomy was prevalent (54%), while lobectomy/bilobectomy was performed in 38%, wedge resection in 5% and pneumonectomy in 3% of all cases respectively. Preoperative high-voltage radiation was given in 70% of them; while adjuvant RT was requested in 17% of cases, mainly because of N1-2 status. Actuarial 5-year survival was 14% with a range of 0% in N2 cases to 21% in NO-1 ones. When considering surgical modes, the en-bloc chest-wall resection had a 5-year survival of 20% while the more limited extrapleural dissection yield only a 9% survival. Compared with the international experience the 14% 5-year survival is standing at the bottom of the scale. On the other hand, 350 patients belong to the other two main groups of peripheral tumors taken in consideration: the ones which, even apical, are yet lying anteriorly far enough from the costo-vertebral angle (apical non Pancoast tumor), and the other ones which are lower placed along the thoracic cage. The majority of these patients (213) were treated by an extrapleural dissection, while the remaining minority (123) received an en-bloc chest-wall resection with 1-2 ribs resected in 46%, 3 ribs in 38% and 4 ribs or more in 16%, respectively. Combined lobectomy/bilobectomy was prevalent (64%), while pneumonectomy was performed in 16%, more limited resections in 16% and exploration alone in 4% respectively. 5-year survival was 18% ranging from 0% in N2 patients to 23% in the NO-1 ones. The extrapleural dissection had a 5-year survival rate of 24.5%, while the en-bloc chest-wall resection yield a lower rate of 15.6%. This overall survival can be indeed considered nearer the international one, even if both surgical approach and the related 5-year survival rates are in full discordance with the compared international references.

Myocardial protection by the leukotriene synthesis inhibitor BAY X1005: importance of transcellular biosynthesis of cysteinyl-leukotrienes

Perfusion of the isolated rabbit heart with 5 x 10(6) human polymorphonuclear leukocytes, under recirculating conditions (50 ml), and challenge with A-23187 (0.5 microM) caused an increase in coronary perfusion pressure (from a prechallenge value of 46 +/- 1.1 to 176.2 +/- 29.7 mm Hg, 30 min after challenge, n = 6-4), which was linearly correlated (P < .006) with formation of cysteinyl leukotrienes (29.7 +/- 7.3 pmol/ml, 30 min after challenge). Pretreatment with the leukotriene synthesis inhibitor BAY X1005 (1 microM) (n = 6) resulted in significant protection against the increase in coronary perfusion pressure (76.7 +/- 12.8 mm Hg, 30 min after challenge) and in almost complete inhibition of sulfidopeptide leukotriene synthesis (3.2 +/- 1.7 pmol/ml, 30 min after challenge). In in vivo experiments, ligation of the left anterior descending coronary artery in the rabbit (n = 10) resulted in acute myocardial infarction marked by a mortality rate of 60% compared with sham-operated animals (n = 10). Intravenous treatment of the rabbits with BAY X1005 (10 mg/kg/h, for 2 h) (n = 10) markedly reduced the mortality rate (20%), protected the rabbits against the marked electrocardiogram derangement and abolished the significant increase in plasma creatine phosphokinase activity and cardiac tissue myeloperoxidase activity induced by coronary artery ligation. BAY X1005 exerts a significant cardioprotection and suggests that specific leukotriene synthesis inhibitors may lead to innovative therapy in myocardial ischemia.

[TNM staging system of lung carcinoma: historical notes, limitations and controversies]

The TNM System as originally proposed by Denoix in 1946, provides a consistent, reproducible description of the anatomic extent of disease in cancer patients at a specific time in the life history of the cancer. C.F. Mountain first adapted this classification to lung cancer in 1973 on behalf of AJCC. In 1986 he presented the "New Intl. Staging System for Lung Cancers" mainly based on a 13 yr experience of the previous one, which was accepted world-wide through a round of international consensus meetings held in 1985. Clinical Staging is the best estimate of disease extent made prior to the institution of any therapy; Surgical-pathological Staging is the classification of disease extent as determined from pathological examination of resected specimens. Accordingly, once the diagnosis is made, it is necessary to stage accurately the tumour determining the size and location of the tumour (T status), the presence or absence of lymphnode involvement (N status), and whether the tumour is metastatic to distant sites (M status). Moreover the uniform staging criteria for lung cancer will assure for each patient the better selection of treatment, the evaluation of operability, the need for adjuvant therapy, as well as the estimation of prognosis. Equally important is the resultant ability to compare the outcome of treatment protocols from different centres. More recently C.F. Mountain has added to the Staging System a new standard logic or "convention" for classifying infrequently observed presentations of lung cancer with which the standard rules of Staging System itself don't fit. These conventions are based on empiric expectation for treatment selection and survival that are similar to those for the Staging definitions, which are based on actuarialsurvival data. Many different types of tumour such as multiple masses, synchronous multiple primitives, discontinuous tumour foci in visceral or parietal pleura as well neoplastic involvement of various mediastinal structures, could be now staged with a major benefit for their treatment protocols. In conclusion the Staging System represents today a standard clinical methodology which basically helps in a better clinical approach to lung cancer even if it cannot fully cover and consider all the innumerable manifestations of the tumor. Therefore, if it is true that in the near future the new molecular predictors of prognosis are expected to measure more deeply the extent of disease, for the present time the International Staging System still continues to act as the best common method for measuring prognosis.

[Adhesive peritonitis caused by a foreign body. A case report]

After investigation of the international literature on this subject, the authors describe a case report of adhesive-stenotic and retractile peritonitis, very likely caused bt a foreign body reaction (surgical stitches, gloves, rice powder, etc.?). This case-report is interesting both to remember the existence of this pathology and to limit its iatrogenic development. In conclusion, it is advisable to wash surgical gloves with sterile solutions and to limit enlarged bowel resections mostly in young people.

[Lobar bronchoplasty for tumor. Surgical technique and long-term results]

Between 1978 and 1994, 55 patients (53 men and 2 women) with a mean age of 62 years underwent an extended lobectomy to the main bronchus, with bronchial re-anastomosis, for bronchogenic tumours located around the lobar orifice. There were 32 upper sleeve lobectomies (58%) with a wedge resection of carina in one instance, 7 lower mono/bilobectomies with an upper lobe "turn up" re-anastomosis (13%) and 16 upper wedge lobectomies (29%). Squamous cell carcinoma was predominant (32 patients, 58%), while the adenocarcinoma was present in 16%, adenosquamous in 5%, microcitoma in 9%, carcinoid in 4% and a well differentiated neuro-endocrine carcinoma in 2%. The indication for the bronchoplastic procedure was judged to be when the FEV, value was about -25% of the normal; in a few patients still in good respiratory condition, an elective indication was also admitted. Postoperative staging was: Stage 0 in 1 patient, Stage I in 7 patients; Stage II in 10 patients; Stage III A in 31 patients; Stage III B in 5 patients and Stage IV in 1 patient. Follow-up was completed with a mean extension of 40 months (range 3 months-16 years). There was no operative mortality in Stages I and II as well as in Stages III B and IV, while it was 9% in Stage III A patients. Survival rates according to the stage were as following: 66% 5 and 10 year for Stage I disease; 56% 5 year and 45% 10 year for Stage II disease; 7% 4 year for Stage III A. None of 5 patients belonging to Stage III B has survived for more than 18 months (mean 7). Some single survivals are mentioned because of their special clinical features. Besides stressing the absolute value of survival rates obtained in Stage I and II disease, the Author also point out the clinical role of these advanced surgical techniques in improving both the survival length and the quality of life, when applied for the treatment of more advanced Stage III A.

[Prognostic significance of cell-mediated immune response in patients with colorectal carcinoma. Preliminary results]

Pre-operative skin test response has been evaluated in 50 cases of colorectal carcinoma. Cellular defense's depression was correlated with tumoral staging (p = < 0.001). In B2 and C groups, a higher incidence of metastatic and local recurrences was registered in subjects with low response. These last are suitable for a randomized trial including immunotherapy.

Extension of lymph node dissection and survival in primary gastric cancer

The histories of 429 patients who underwent surgery for primary gastric cancer at our ward from January 1970 to December 1985, were reviewed. All patients underwent surgery: potentially curative surgery, 54.8%, non-curative resection, 18.2%; palliative surgery, 27%. Nodal status was as follows: N0, 28%; N1, 17.7%; N2, 44.5%; N3, 9.8%. The incidence of N0 cases was significantly increased in Stage T1 and T2 disease compared to Stage T3 and T4 lesions (p < 0.001). In Stage T3 and T4 patients the incidence of distant metastases increased if lymph node involvement was also present (p < 0.005). In patients without nodal metastases 5-year survival was 70% (median survival: 60+ months) whereas, in patients with lymph node involvement survival was 32% (median survival: 24 months) (p < 0.001). Our data suggest that elective extensive lymph node dissection (R2) is indicated in all patients because survival is improved by this procedure. We recommend R3 lymph node dissection only in macroscopic N3 node involvement patients.

[Spigelian hernia: its echotomographic diagnosis and surgical treatment]

A case of Spigelian hernia recently observed gives the chance to review the anatomic features of this pathology. Spigelian hernia is seldom suspected, owing to its rare incidence. Currently, ultrasonography seems to resolve diagnostic problems with an accuracy of 86%. Consequent surgical treatment such as simple hernioplasty is easy, and the risk of recurrence is very small.

[Idiopathic and torsion-induced omental infarct: case reports and a review of the literature]

The authors review nosologic problems related to the infarction of the greater omentum on the ground of two cases (one idiopathic, the other by torsion) recently observed. Omental infarction, far from being a real diagnostic or surgical problem, is an unusual cause of acute abdomen; resection of the affected omentum is curative in 100% of cases.

[Acute appendicitis secondary to carcinoma of the right colon]

In a series of 954 laparotomies performed for suspected acute appendicitis 5 (0.5%) cecal carcinomas were encountered. When considering patients over 50 years of age only, the incidence of right sided colon carcinomas raised to 5%. The authors review the therapeutic options in order to optimize patients' survival.