Genomic instability and cellular stress in organ biopsies and peripheral blood lymphocytes from patients with colorectal cancer and predisposing pathologies.

Inflammatory bowel disease (IBD) and polyps, are common colorectal pathologies in western society and are risk factors for development of colorectal cancer (CRC). Genomic instability is a cancer hallmark and is connected to changes in chromosomal structure, often caused by double strand break formation (DSB), and aneuploidy. Cellular stress, may contribute to genomic instability. In colorectal biopsies and peripheral blood lymphocytes of patients with IBD, polyps and CRC, we evaluated 1) genomic instability using the γH2AX assay as marker of DSB and micronuclei in mononuclear lymphocytes kept under cytodieresis inhibition, and 2) cellular stress through expression and cellular localization of glutathione-S-transferase omega 1 (GSTO1). Colon biopsies showed γH2AX increase starting from polyps, while lymphocytes already from IBD. Micronuclei frequency began to rise in lymphocytes of subjects with polyps, suggesting a systemic genomic instability condition. Colorectal tissues lost GSTO1 expression but increased nuclear localization with pathology progression. Lymphocytes did not change GSTO1 expression and localization until CRC formation, where enzyme expression was increased. We propose that the growing genomic instability found in our patients is connected with the alteration of cellular environment. Evaluation of genomic damage and cellular stress in colorectal pathologies may facilitate prevention and management of CRC.

Acute thrombosis of the superior mesenteric artery in a 39-year-old woman with protein-S deficiency: a case report.

INTRODUCTION: Acute thromboembolic occlusion of the superior mesenteric artery is a condition with an unfavorable prognosis. Treatment of this condition is focused on early diagnosis, surgical or intravascular restoration of blood flow to the ischemic intestine, surgical resection of the necrotic bowel and supportive intensive care. In this report, we describe a case of a 39-year-old woman who developed a small bowel infarct because of an acute thrombotic occlusion of the superior mesenteric artery, also involving the splenic artery. CASE PRESENTATION: A 39-year-old Caucasian woman presented with acute abdominal pain and signs of intestinal occlusion. The patient was given an abdominal computed tomography scan and ultrasonography in association with Doppler ultrasonography, highlighting a thrombosis of the celiac trunk, of the superior mesenteric artery, and of the splenic artery. She immediately underwent an explorative laparotomy, and revascularization was performed by thromboendarterectomy with a Fogarty catheter. In the following postoperative days, she was given a scheduled second and third look, evidencing necrotic jejunal and ileal handles. During all the surgical procedures, we performed intraoperative Doppler ultrasound of the superior mesenteric artery and celiac trunk to control the arterial flow without evidence of a new thrombosis. CONCLUSION: Acute mesenteric ischemia is a rare abdominal emergency that is characterized by a high mortality rate. Generally, acute mesenteric ischemia is due to an impaired blood supply to the intestine caused by thromboembolic phenomena. These phenomena may be associated with a variety of congenital prothrombotic disorders. A prompt diagnosis is a prerequisite for successful treatment. The treatment of choice remains laparotomy and thromboendarterectomy, although some prefer an endovascular approach. A second-look laparotomy could be required to evaluate viable intestinal handles. Some authors support a laparoscopic second-look. The possibility of evaluating the arteriotomy, during a repeated laparotomy with a Doppler ultrasound, is crucial to show a new thrombosis. Although the prognosis of acute mesenteric ischemia due to an acute arterial mesenteric thrombosis remains poor, a prompt diagnosis, aggressive surgical treatment and supportive intensive care unit could improve the outcome for patients with this condition.

[Laparoscopic approach in acute appendicitis: experience with 501 consecutive cases]. / Approccio laparoscopico nelle appendiciti acute: l'esperienza di 501 casi consecutivi.

Appendicitis is an acute disease requiring urgent surgical treatment. Acute appendicitis is the most common surgical emergency in children and young adults, with an incidence of about 100-140 cases per 100,000 people. In our study we analyse 501 consecutive appendectomies performed in our department. From June 2003 to December 2008 we performed 501 appendectomies, 287 in male and 214 in female patients. The average age was 27.99 years (range: from 4 to 94 years). We routinely perform a laparoscopic approach with a standard protocol for patient selection. Following a standard protocol, 429 patients were selected for the laparoscopic approach and 72 for an open appendectomy. In 411 patients (95.8%) the surgical procedure was completed in laparoscopy with a conversion rate of about 4.2% (18/429). The conversion rate in the simple appendectomy subgroup was 0.98%, as against about 12.1% in the complex appendectomy subgroup. The open appendectomy group comprised 72 patients, 27 patients treated with an open approach by choice, 26 for necessity and 19 for protocol violation. There were 9 post-appendectomy complications (2.1%) and 3 re-operations (0.5%); the mortality rate was nil. Although 20 years have passed since the first laparoscopic appendectomy, today it is still debated whether or not the laparoscopic approach is the correct surgical procedure for the treatment of acute appendicitis. Several studies have shown that laparoscopic appendectomy presents a number of advantages in terms of a shorter hospital stay, less postoperative pain and fewer wound infections. Some authors, however, have demonstrated that the laparoscopic approach for acute appendicitis is associated with increased operative times and risk of intra-abdominal abscesses (above all if the appendix is perforated). Our experience confirms that the routinely performed laparoscopic approach to treat acute appendicitis is associated with a low rate of abscess complications: in our series some of the complications could be attributed to the surgical learning curve.

[Acute abdomen due to anisakidosis]. / Addome acuto da anisakidosi ileale.

Anisakidosis is the infestation of man by the larval stage of the parasite Anisakis simplex. A history of ingestion of raw or undercooked fish up to 48-72 hours before the onset is highly orientative. Based on the location of the lesions, various types of human anisakidosis have been identified: gastric, intestinal and luminal forms constitute the majority of cases and symptoms often mimic a variety of acute conditions such as gastritis, acute appendicitis, diverticulitis, or ileitis. We present a case of a young woman admitted to our department with acute abdominal pain. A history of raw fish ingestion was recorded. The patient was submitted to explorative laparoscopy in which an oedematous, thickened segment of ileum was observed. Therefore a small laparotomy was performed, followed by resection of the thickened ileum. The histological examination revealed transmural inflammation with marked infiltration of eosinophils. High levels of total IgE and Anisakis simplex-specific IgE were recorded. Anisakidosis is an underestimated cause of acute abdomen, and should be taken into consideration as a differential diagnosis in these conditions. Nevertheless, in most cases, the correct approach could prove difficult, because surgery may be necessary in these settings, allowing the diagnosis only by histological and parasitological investigation of the resected specimen.

Colorectal cancer in the elderly. Is there a role for safe and curative surgery?

BACKGROUND: Recent reports place colorectal cancer (CRC) as the third most common cancer for both sexes. Elderly patients are often viewed as high-risk surgical candidates with high rates of emergency presentations and perioperative mortality. The aim of our study was to examine the characteristics and perioperative morbidity and mortality rates of elderly patients presented to CRC surgery. METHODS: We retrospectively studied 248 patients who underwent surgery for CRC at our institution between July 2003 and December 2005. Risk factors included sex, age, cancer localization, Dukes' and TNM classification, blood transfusion, preoperative Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity score and mode of presentation. Primary outcome was perioperative death. RESULTS: The study consisted of 143 men and 105 women. One hundred and thirty-four (54%) patients were more than 75 years of age. In the two older groups, cancer was more common in the proximal colon than in the youngest age group (P = 0.001). Of the 25 resections carried out as emergency, 20 were in those who were more than 75 years of age (P < 0.001). In elective procedure, perioperative mortality scores were 3.1% in those who were more than 75 years of age versus 0% in those less than 75 years, meanwhile in emergency, rates of 24 versus 0% (P = not significant) were registered. In Cox multivariate regression analysis, age and mode of presentation reached statistical significance. CONCLUSION: Old age itself is not an independent negative prognostic factor for CRC surgery. Although emergency operations were associated with poor outcome, most patients survived and left the hospital. This study suggests that, whenever possible, curative intent should be applied in patients with CRC, irrespective of the age.

Laparoscopic treatment of caecal diverticulitis.

Right-sided diverticulitis is difficult to distinguish from other sources of right-sided abdominal pain and, in particular, is frequently indistinguishable from acute appendicitis preoperatively. Because of the problems concerning preoperative diagnosis and controversies in the management, the choice of the best therapy on the surgeon's part is still open. A total of 1150 patients with a clinical diagnosis of right acute abdomen observed in our surgical department from 1995 to 2003 was analysed. Three patients had a pathologically confirmed diagnosis of caecal diverticulitis. The mean age of the patients was 37 years. Right lower quadrant pain and local tenderness were the only clinical findings in 95.3% of the cases, with a preoperative diagnosis of acute appendicitis in 2 of 3 patients. The operative findings were an inflammatory mass in the caecum and the presence of a minimal amount of free peritoneal fluid. Two patients underwent laparoscopic ileocecectomy and one had a diverticulectomy. The postoperative course was uneventful. Because of the difficulties in diagnosis and surgical treatment, caecal diverticulitis has been the subject of much discussion in the literature and many questions remain unanswered. Right-sided diverticulitis is easily confused with acute appendicitis because it occurs at a somewhat younger age than sigmoid diverticulitis. Caecal diverticulitis needs a high index of suspicion for achieving a preoperative diagnosis. Diverticulectomy should be performed in patients with small diverticula with a limited inflammatory reaction. Right colectomy should be performed in patients with perforation of the diverticulum, caecal phlegmon or abscess formation. A correct intraoperative diagnosis is therefore crucial for selection of the surgical procedure. Laparoscopic treatment of a solitary, acutely infected colon diverticulum is feasible in this setting. A minimally invasive procedure could be performed, therefore, in patients with right acute abdomen, allowing not only the right diagnosis but also the treatment of the commonest pathologies responsible for this clinical picture.