[Doppler-guided transanal haemorrhoidal dearterialisation: a casuistic contribution]. / Dearterializzazione emorroidaria transanale Doppler-guidata: contributo casistico.

The search of innovative procedures, able to associate the possibility of treating the hemorrhoidal disease with of "mini-invasiveness", is of growing interest. This paper reports the results obtained during our experience in threating the hemorrhoidal disease with Doppler-guided THD (Transanal Hemorroidal Dearterialisation), which is a technique improved in the last 4 years (February 2004 - November 2009) on a sample of 408 patients. The aim of this study is to evaluate, in a short-term follow-up period, the level of satisfaction and post-operative pain, normal working routine recovery time and the incidence of early and late post-operative complications in our patients. Our results encourage the use of this technique which appears to be safe, quickly performed and characterized by minimal pain and low incidence of complications in the post-operative period.

Total anorectal reconstruction by double graciloplasty: experience with delayed, selective use of implantable pulse generators.

This study reports our experience with total anorectal reconstruction (TAR), supported at a later phase, whenever necessary, by an implantable pulse generator. Thirteen patients underwent total anorectal reconstruction by double graciloplasty, diverting loop colostomy, and implantation of temporary electrodes. External-source, short-term, intermittent electrostimulation and biofeedback were used for neosphincter voluntary control training. After abdominal stoma closure, 6 months after initial surgery in disease-free patients, functional results were evaluated by a scoring system and anomanometry. A pulse generator was implanted whenever continence was judged unsatisfactory. After continuous electrostimulation training, neosphincter function was reassessed. Major graciloplasty complications (partial muscle necrosis and perineal colostomy necrosis) were treated successfully by surgery. One death of myocardial infarction occurred after discharge. Three patients refused further surgery. One patient did not undergo abdominal stoma closure because of early hepatic metastases. Functional evaluation after closure (eight patients) showed the following results: two "excellent" (no pulse generator implanted), three "good" (two stimulator implantations, with an "excellent" result), two "fair", and one "poor" (3 implantations, with a "good" result). In addition to improving clinical results (P=0.042), resting anal pressures were also increased significantly by active an implantable pulse generator (P=0.043). Although stimulators, whenever implanted, improved the neosphincter function, delayed, selective use of these in some cases rendered an implantable pulse generator either unnecessary from a functional viewpoint or redundant because of cancer recurrence or infectious complications. Drawbacks to the procedure were poor patient compliance to neosphincter training and to multiple surgical procedures, and excessive wasting of human resources during training for intermittent electrostimulation and biofeedback.

[Tumefaction of the parotid region. The clinico-surgical experience of 3 years]. / Tumefazioni della regione parotidea. Esperienza clinico-chirurgica di un triennio.

The pathologic processes involving the parotid gland area include a vast, heterogeneous group of lesions, consisting of dysembryopathies, traumas, acute and chronic inflammation, degenerative manifestations, benign tumours and both primary and secondary malignancies. This gland, or rather the whole parotid gland area, can be a site of secondary invasion, due to the presence of intra- and peri-parotid lymph nodes; the metastases usually deriving from small, sometimes unrevealed tumours. Treatment of parotid gland tumours is mainly surgical; in most cases the choice of therapy depends on the clinical features and the results of preoperative diagnostic tests. This paper presents our experience during the last three years of clinico-surgical activity in this field and discusses the treatment of primary and secondary tumours of the parotid gland area.

Double-gracilis anorectal neosphincter: technique of reconstruction after necrosis of the distal part of the muscles.

PURPOSE: The aim of the present study is to demonstrate further reconstruction of a double-gracilis anorectal neosphincter that had been destroyed because of a severe postoperative perineal infection, with necrosis of the distal part of the muscles. METHOD: Each residual gracilis muscle was split longitudinally into two branches, which surrounded the neorectum, one posteriorly and the other one anteriorly, so as to perform a perineorectal double sling. RESULT: Owing to a poor functional result, continence was achieved only by the support of an implantable pulse generator. CONCLUSION: This technique seemed to permit the optimum use of the contractile potential of the residual gracilis muscles, which did not show evidence of defunction-related or ischemia-related fibrosis.

[Surgical reconstruction of the external nose: personal experience]. / Chirurgia riparativa della piramide nasale. Esperienza personale.

Because of the ensuring malformations, most often vascular in nature, malignant tumors of the nasal pyramid often require partial or total exeresis of the nasal structures. These tumors are most commonly basal cell carcinoma (85-90%) and squamous cell carcinoma (7-8%). A recent epidemiological survey performed in Italy showed that, in this country, such carcinomas account for approximately 13% of all malignant cutaneous neoplasms of the head and neck region. This work presents the author's personal experience in 8 cases of partial, subtotal and total reconstruction of the nose, performed over 5 years of clinical activity. The cases include 8 patients (4 males and 4 females, age range 48-95 years, mean age 77.3 years): 7 cases of malignant cutaneous nasal tumors (5 basal cell, 1 squamous cell and 1 basal-squamous cell carcinoma) and 1 case of iatrogeneous perforation through the entire thickness of the right nasal wall, approximately 7-8 mm in diameter, the outcome of sclerotizing treatments initiated 30 years before for angioma. On the whole, including the case of iatrogeneous nasal perforation the following procedures were used: 7 frontal fascio-cutaneous flaps and 1 nasal-genienic flap associated with a median of upper lip muscle. As regards the frontal flaps, in 5 cases a variation was used where the inset base was set more medially and with dimensions different from up-and-down Converse flaps. In 2 other cases a median frontal flap was used. Except for one case of partial necrosis of the flap, healed by subsequent surgery, complications were not particularly important from the clinical point of view and occurred in the broadest exeresis, where reconstruction of the structures adjacent to the nose and the mucosa lining proved necessary. On the whole, considering the initial stages of the lesions and the often advanced age of the patients, the surgical treatment gave good results from the oncological, aesthetic and functional points of view.

Therapy of murine tumors with p53 wild-type and mutant sequence peptide-based vaccines.

The BALB/c Meth A sarcoma carries a p53 missense mutation at codon 234, which occurs in a peptide, termed 234CM, capable of being presented to cytotoxic T lymphocytes (CTL) by H-2Kd molecules (Noguchi, Y., E.C. Richards, Y.-T. Chen, and L.J. Old. 1994. Proc. Natl. Acad. Sci. USA. 91:3171-3175). Immunization of BALB/c mice with bone marrow-derived dendritic cells (DC), generated in the presence of granulocyte macrophage colony-stimulating factor and interleukin 4, and prepulsed with the Meth A p53 mutant peptide, induced CTL that specifically recognized peptide-pulsed P815 cells, as well as Meth A cells naturally expressing this epitope. Immunization with this vaccine also protected naive mice from a subsequent tumor challenge, and it inhibited tumor growth in mice bearing day 7 subcutaneous Meth A tumors. We additionally determined that immunization of BALB/c mice with DC pulsed with the p53 peptide containing the wild-type residue at position 234, 234CW, induced peptide-specific CTL that reacted against several methylcholanthrene-induced BALB/c sarcomas, including CMS4 sarcoma, and rejection of CMS4 sarcoma in vaccination and therapy (day 7) protocols. These results support the efficacy of DC-based, p53-derived peptide vaccines for the immunotherapy of cancer. The translational potential of this strategy is enhanced by previous reports showing that DC can readily be generated from human peripheral blood lymphocytes.

Continent perineal colostomy by electrostimulated graciloplasty in abdominoperineal resection. A preliminary report.

Despite the tendency toward sphincter-saving surgical procedures, a small proportion of rectal cancers must still be treated by abdominoperineal resection (APR). The physical, psychological and social consequences of a permanent abdominal stoma are a challenge to perform a continent perineal colostomy. Most of the attempts originate from experiences with gracilis muscle transposition in the treatment of fecal incontinence, in particular Pickrell's operation. Functional results are however conditioned by the fact that the transposed muscle takes up a different function and its natural evolution, if not adequately stimulated, consists of atrophy and fibrosis. The most important series of graciloplasty in APR is reported by Cavina and coworkers (75 cases from 1985 to 1993), who at first obtained good functional results by external electromyostimulation (EMS) and biofeedback, then registered a further improvement using internal, continuous low-frequency EMS by implantable pulse generators (IPG). The surgical technique involves, after APR: bilateral dissection of the gracilis up to the proximal neurovascular pedicle and detachment of the distal tendon; mobilization of the muscles, through the subcutaneous tissue, into the perineum, where the colonic stump is drawn out; positioning the right gracilis behind the colonic stump, as a puborectalis sling, and the left gracilis around it, in a sort of "alpha" configuration; suturing the colonic stump to the perineal skin; optionally, temporary diverting loop colostomy. The operation is completed by the insertion of two electrodes near the nerve, for external or internal EMS (in the last case: implantation of IPG). The external EMS may be carried out by current cardiac temporary electrodes, drawn up through the skin of the iliac area. It is aimed at preserving the trophism and the contractility of the muscle and enabling the patient to learn a new function of continence (actually, it is a "pseudocontinence"), thanks to a program of intermittent stimulation and biofeedback. Electrodes and other devices are not expensive. The internal EMS requires specific electrodes, connected to an IPG, implanted in a subcutaneous abdominal pocket. The continuous stimulation gives rise to a tonic activity of the gracilis, resulting in higher resting anal pressure and "true" continence. The IPG is programmed under telemetry control, step by step until the most suitable EMS parameters are reached. A magnet allows the patient to turn the IPG "off" of "on", according to the necessity to void the bowel. A complete set of 1 IPG and 2 electrodes costs about $10,000. Cavina reports good continence in 71% of the cases treated by external EMS and 100% of the patients with IPG. Our first graciloplasty in APR was performed in April 1994. Since then we have carried out 6 operations. Because of its high cost, we decided that, at least at a first phase, the IPG should be implanted, from the 7th month on, only in disease-free patients, when functional results suggested a possible clinical improvement. Until today, 3 patients have had the abdominal stoma closed and can be evaluated from a functional viewpoint. We recorded 1 "excellent" and 2 "fair" results. In the two patients with a "fair" result we implanted a pulse generator about a month after the closure of the abdominal colostomy. A good manometric and clinical improvement was registered. The patient with "excellent" functional result had a recurrence one month after the closure of the stoma. Though limited, our experience is absolutely favourable as to graciloplasty, but an evaluation from us whether external or internal EMS is better, is too early at the moment. In absolute functional terms, the internal, continuous EMS is preferable, but problems of cost and oncologic prognosis restrict the use of IPG.

[Jejunal carcinoma: apropos 8 cases]. / Il carcinoma del digiuno: a proposito di 8 casi.

The tumors of the small bowel are uncommon. About one-third are jejunal, for the most part adenocarcinomata. From 1976 to 1994 we operated on 8 patients affected by jejunal adenocarcinoma, mean age 59 years (+/- 15.2), range 37-78, which are 0.33% of all the malignant epithelial neoplasms of the digestive tract, treated in the same period. In six cases the diagnosis was preoperative, by x-ray or instrumental investigations. In the other two patients the neoplasm was found intraoperatively. Only five operations were curative. In six cases the neoplasm invaded the serosa and, in three, also the mesenterium. A chemotherapy was carried out in the last five patients. One of these underwent right hepatectomy for single metastasis, 26 months after the primary operation. Until now we registered three deaths, one of which for causes unrelated to the cancer. After discussing epidemiology and diagnostics, the authors evaluate the therapeutical possibilities, mainly consisting of surgery, and dwell upon technical aspects and results.