Severe necrotic and septic pancreatitis. Indications to endoscopic, surgical, and nutritional therapy

Severe acute pancreatitis (SAP) management has changed over the last fifteen years, and from too aggressive behaviour, we moved to a cautious one. In every case, we can appreciate defect of extremist conceptual position. We reviewed our strategy on disease treatment, and we analyzed treatment of single cases. We collected 4 SAP cases from January 2009 to January 2010. All patients were septic, and we adopted the same approach for all of them, avoiding surgery without peritoneal infection. In all patients we placed jejumostomy and, after cleaning of septic site, we started immediate enteral nutrition (EN). Antibiotic therapy against Gram+, Gram- and antifugal drug had been started. No one died and all patients were back to an active life even if social costs are considerably high especially due to very long hospital stay.

One stage or two stage treatment of colorectal cancer associated to abdominal aortic aneurysm: morbidity and mortality

The coexistence of colorectal cancer and abdominal aortic aneurysm has been observed with increasing frequency, raising several questions about therapeutic and surgical strategies for management of both diseases. This study has reviewed 440 cases (359 cases analyzed) of colorectal cancer associated with abdominal aortic aneurysm recovered in the literature from year 1987 to 2010. In 120 cases, patients were treated in one stage; in 239 cases, they were treated in two stages. The treatment in two stages was associated with a morbidity of 26.4%, with a mortality of 5% and prosthetic infection of 0.8%. The treatment in one stage had rates of complications and mortality of 13.3% and 4.2% respectively and no cases of prosthetic infection. Analysis of the literature shows that the treatment in two stages exposes patients to a higher risk of complications and prosthetic infection.

Shape and volume of internal anal sphincter showed by three-dimensional anorectal ultrasonography

PURPOSE

The aim of this work is to characterize the shape and the volume of the internal anal sphincter (IAS) in normal subjects by three-dimensional anorectal ultrasonography.

METHODS

Thirty-nine normal volunteer males (mean age 58.5 ± 18.7) and 25 females (mean age 59.4 ± 14.1) were submitted to anorectal ultrasonography. The tissue is defined by a semiautomatic procedure. Measurements of thickness, length and volume were assessed automatically. The software provides an average number of 57,600 thickness measurements, 360 length measurements for each zone (90 for each quadrant) and seven volume measurements (one for each anatomical area).The mean values of magnitudes were calculated for the entire volume in each quadrant and zone. Age and gender-related variations were analyzed.

RESULTS

In assessments of the whole tissue, only thickness was gender-related, with greater thickness for females (male thickness: 1.81 ± 0.47 mm, female thickness 2.16 ± 0.57 mm, P-value<0.01).In the distal zone: thickness, length and volume were all larger in females (for male and female respectively: 1.83 ± 0.49 mm vs 2.34 ± 0.58 mm, P-value<0.01, for the thickness; 10.87 ± 2.10mm vs 12.18 ± 2.21 mm, P-value<0.02 for the length and 1501 ± 605 mm(3) vs 2169 ± 871 mm(3), P-value<0.01 for the volume). In the medial zone, only thickness was gender-related, with greater thickness in females (male thickness: 2.04 ± 0.60mm, female thickness:2.44 ± 0.74 mm, P-value<0.02).The only variation observed in the proximal zone concerned length, larger in males (respectively: 11.27 ± 2.84 mm vs 9.55 ± 2.43 mm, P-value<0.02). The male population was significantly positively correlated with ageing for volume in the whole tissue (ρ = 0.32, P-value<0.05), and for both thickness and volume in the medial zone (ρ = 0.33, P-value<0.05 for thickness; ρ = 0.39, P-value<0.02 for the volume).

CONCLUSION

This new method is useful to understand both functional anal disorders and local damage which may affect only part of the muscle tissue.

Investigations of 5S rDNA of Vitis vinifera L.: sequence analysis and physical mapping

Here we report the first results of a study of 5S rDNA of Vitis vinifera . 5S rDNA sequences from seven genotypes were amplified by PCR, cloned, and sequenced. Three types of repeats were found. Two variants, denominated long repeat and short repeat, appeared to be the main components of the 5S rDNA of this species, since they were found in all genotypes analyzed. They differed markedly from each other in both the length and the nucleotide composition of the spacers. The third variant, classified as DEL short repeat, differs from the short repeat owing to a large deletion in the spacer region. It appears to be the most recent repeat type, since it was identified in only one genotype. The organization of the 5S rDNA repeat unit variants was investigated by amplifying the genomic DNA with primers designed on the sequence of the long and short spacers. The PCR-amplified fragments showed that the long repeat is associated with the other two repeats, indicating that in V. vinifera different repeat units coexist within the same tandem array. FISH analysis demonstrated that 5S rRNA genes are localized at a single locus. The variability of 5S rDNA repeats is discussed in relation to the putative allopolyploid origin of V. vinifera.

Updated results, multivariate and subgroups analysis confirm improved activity and efficacy for FOLFOXIRI versus FOLFIRI in the G.O.N.O. randomized phase III study in metastatic colorectal cancer (MCRC)

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Background: As previously reported (ASCO 2006) the G.O.N.O. conduced a phase III study comparing FOLFIRI to FOLFOXIRI in 244 patients (pts) with not resectable MCRC. At a median follow-up of 18.4 months (mos) we reported significant improvements in response-rate (RR), R0 resection of metastases (mts), PFS and OS for FOLFOXIRI. Methods: Results have been updated (median follow-up of 36.2 mos) and 14 variables were tested as possible prognostic factors for response, R0 resection, PFS and OS. Results: At this updated analysis 225 (111 vs 114) pts have progressed and 180 (84 vs 96) have died. Results confirm the significant improvements for FOLFOXIRI in terms of confirmed RR (60% vs 34% p<0.001), R0 resection of residual mts (15% vs 6% p=0.033 and 36% vs 12% p=0.017 for pts with liver only mts), PFS (median 9.8 vs 6.9 mos p<0.001) and OS (median 23.6 vs 16.7 mos p=0.042) at the cost of a modest and acceptable increase in toxicity. In the logistic regression multivariate analysis treatment with FOLFOXIRI was the only independent predictive factor for response (HR:2.9, p<0.001) and for achieving an R0 surgical resection of mts (HR:3.1, p=0.018). The Cox’s multivariate analysis demonstrates that independent prognostic factors for improved time to progression were treatment with FOLFOXIRI (HR:0.64, p<0.001), and ECOG PS = 0 (HR:0.73, p=0.02) and for time to death were treatment with FOLFOXIRI (HR:0.74, p=0.04) and liver involvement <25% (HR:0.57, p=0.006). The benefits of FOLFOXIRI was consistent across all subgroups, including those with unfavorable prognosis such as pts with time from diagnosis to randomization <3 mos, multiple site of disease or liver involvement ≥ 25%. Conclusions: FOLFOXIRI confirms to be the first combination demonstrated to be superior to an infusional 5FU containing doublet as FOLFIRI in terms of RR, R0 resections, PFS and OS. FOLFOXIRI represents a new treatment option in MCRC and its use and study is of particular interest in a neoadjuvant strategy, in pts with few chances to achieve a three-drug exposure in a sequential strategy and in combination with targeted agents. Partially supported by Fondazione ARCO.

No significant financial relationships to disclose.