Potential benefits of pro- and prebiotics on intestinal mucosal immunity and intestinal barrier in short bowel syndrome.

The mechanism of impaired gut barrier function in patients with short bowel syndrome (SBS) is poorly understood and includes decreased intestinal motility leading to bacterial overgrowth, a reduction in gut-associated lymphoid tissue following the loss of intestinal length, inhibition of mucosal immunity of the small intestine by intravenous total parental nutrition, and changes in intestinal permeability to macromolecules. Novel therapeutic strategies (i.e. nutritive and surgical) have been introduced in order to prevent the establishment or improve the outcome of this prevalent disease. Pre- and probiotics as a nutritive supplement are already known to be very active in the intestinal tract (mainly in the colon) by maintaining a healthy gut microflora and influencing metabolic, trophic and protective mechanisms, such as the production of SCFA which influence epithelial cell metabolism, turnover and apoptosis. Probiotics have been recommended for patients suffering from SBS in order to decrease bacterial overgrowth and prevent bacterial translocation, two major mechanisms in the pathogenesis of SBS. The present review discusses the research available in the international literature, clinical and experimental, regarding probiotic supplementation for this complicated group of patients based on the clinical spectrum and pathophysiological aspects of the syndrome. The clinical data that were collected for the purposes of the present review suggest that it is difficult to correctly characterise probiotics as a preventive or therapeutic measure. It is very challenging after all to examine the relationship of the bacterial flora, the intestinal barrier and the probiotics as, according to the latest knowledge, demonstrate an interesting interaction.

Antioxidant properties of probiotics and their protective effects in the pathogenesis of radiation-induced enteritis and colitis.

Radiation therapy has become one of the most important treatment modalities for human malignancy, but certain immediate and delayed side-effects on the normal surrounding tissues limit the amount of effective radiation that can be administered. After exposure of the abdominal region to ionizing radiation, nearly all patients experience transient symptoms of irradiation of the bowel. Acute-phase symptoms may persist for a short time, yet long-term complications can represent significant clinical conditions with high morbidity. Data from both experimental studies and clinical trials suggest the potential benefit for probiotics in radiation-induced enteritis and colitis. On the other hand, it is well evidenced that both useful and harmful effects of therapeutic applications of ionizing radiation upon living systems are ascribed to free-radical production. Therefore, the hypothesis that probiotics reinforce antioxidant defense systems of normal mucosal cells exposed to ionizing radiation may explain to an extent their beneficial action. The aim of this review is threefold: First, to make a short brief into the natural history of radiation injury to the intestinal tract. Second, to describe the primary interaction of ionizing radiation at the cellular level and demonstrate the participation of free radicals in the mechanisms of injury and, third, to try a more profound investigation into the antioxidant abilities of probiotics and prebiotics based on the available experimental and clinical data.

Surgical treatment of giant mesenteric fibromatosis presenting as a gastrointestinal stromal tumor: a case report.

INTRODUCTION: Intra-abdominal fibromatosis, usually located at the mesenteric level, is a locally invasive tumor of fibrous origin, with no ability to metastasize, but a tendency to recur. Certain non-typical cases of intra-abdominal fibromatosis with involvement of the bowel wall can be misdiagnosed because of their different biological behavior. CASE PRESENTATION: We describe the case of a 64-year-old Caucasian man presenting with mesenteric fibromatosis and involvement of the bowel wall, who was treated surgically. The macroscopic and microscopic appearance of the lesion mimicked a gastrointestinal stromal tumor, a tumor with potential malignant behavior. CONCLUSION: It is essential to make an early and correct diagnosis in such equivocal cases, so that the appropriate treatment can be chosen and suitable patients admitted to clinical trials if appropriate. New and reliable criteria for discriminating between intra-abdominal fibromatosis and gastrointestinal stromal tumor should be proposed and established because novel sophisticated therapeutic strategies have been introduced in the international literature.

Diffuse anorectal melanoma; review of the current diagnostic and treatment aspects based on a case report.

Primary anorectal melanoma is a rare and aggressive disease. Patients commonly complain for changes in bowel habits and rectal bleeding, and proctoscopically they mostly appear as non pigmented or lightly pigmented polypoid lesions. Such a lesion should always raise a high index of suspicion in any gastroenterologist or surgeon to prompt surgery, since early radical excision is the only treatment option.Herein, we report a case of a 57-year-old man with a diffuse anal canal melanoma and give reference to the current diagnostic and treatment options.

Spontaneous regression of a true splenic cyst: a case report and review of the literature.

Splenic cysts are rare clinical findings, detected due to derivative symptoms or as a random discovery in abdominal imaging. Although there still remains controversy as to their optimal treatment, bigger secondary cysts should be treated surgically. However, spontaneous regression may be observed in cysts with a diameter smaller than 4 cm. In these cases, expectant treatment is preferable. We report, herein, a single case of a splenic cyst in an adult woman, who reported minor symptoms despite the size of the lesion and who demonstrated a possible almost total regression of the cyst within a ten-year period, accompanying with review of the most recent literature.

Role of probiotics, prebiotics and synbiotics in chemoprevention for colorectal cancer.

Colorectal cancer is the third most common form of cancer. Current treatments are all associated with a high risk of complications and a low success rate. Recently, synbiotics have been proposed as a new preventive and therapeutic option. There is no direct experimental evidence for cancer suppression in humans as a result of the consumption of pro-, pre- or synbiotics. However, there is a wealth of evidence emerging from laboratory studies. The mechanisms by which pro-, pre- and synbiotics may inhibit colon cancer are now beginning to be understood and will be addressed in the present review.

Evaluation of pain experienced during breast ductal endoscopy.

PURPOSE: Ductal endoscopy is valuable for the differential diagnosis of bloody nipple discharge; however, the pain associated with this procedure has not been evaluated. This study aims to assess the pain experienced by patients during ductal endoscopy. METHODS: We studied a consecutive series of women who underwent ductal endoscopy, to investigate the cause of bloody nipple discharge. The procedure was performed using standard local anesthesia (lidocaine 1% 10 ml without epinephrine, involving nipple block and periaureolar administration). Patients were asked to score the level of pain with a visual analog scale, 1, 4, 7, 12, 17, 22, 27, and 32 min after the procedure, and describe their overall and maximum pain. RESULTS: This series comprised 20 women aged from 27 to 68 years old. The overall pain (mean +/- SE) score was equal to 5.8 +/-0.3, and the maximum pain score was 8.3 +/- 0.2. The peak of pain corresponded with when the dilator was inserted through the sphincter. The group in which the dilator was inserted after 4 min experienced more intense maximum and overall pain after 7, 12, 17 and 22 min. CONCLUSIONS: Pain is an important factor in ductal endoscopy, and peaks relatively early. A standard, baseline local lidocaine dose of greater than 10 ml may be necessary at the beginning of the procedure. Late insertion of the dilator seems to be an indicator of the force of the procedure.

Minimizing underestimation rate of microcalcifications excised via vacuum-assisted breast biopsy: a blind study.

PURPOSE: The main disadvantage of Vacuum Assisted Breast Biopsy (VABB) is the probability of underestimating atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS). This study evaluates a modified way of performing VABB. METHODS: 266 women with microcalcifications graded BI-RADS 3&4 underwent VABB (11G) on the Fischer's table. 133 women were allocated to the "standard" protocol and 24 cores were obtained (1 offset-main target and one additional offset). 133 women were randomly allocated to the "extended" protocol and 96 cores were excised (one offset- main target and 7 peripheral offsets). A preoperative diagnosis was established, and the removed volume was calculated. When precursor or malignant lesions were diagnosed, open surgery was performed. A second pathologist, blind to the preoperative results and to the protocol made the postoperative diagnosis. The discrepancy between preoperative and postoperative diagnoses was evaluated. RESULTS: When the standard protocol was applied, the underestimation rate for preoperative ADH, lobular neoplasia (LN), DCIS was 16.7%, 50% and 14.3% correspondingly. In the extended protocol, no underestimation was present in LN, ADH, but the underestimation rate for DCIS was 6.3%. In the extended protocol, no precursor/malignant tissue was left after VABB in all ADH cases, in 87.5% of LN cases, in 73.3% of DCIS, and in 50% of invasive carcinomas. The volume excised was 2.33 +/- 0.60 cc and 6.14 +/- 1.30 cc for the standard and the extended protocol, respectively. The rate of hematoma formation did not differ between the two protocols. CONCLUSIONS: This recently introduced, "extended" way of performing VABB in microcalcifications safely minimizes the underestimation rate, which may lead to a modified management of ADH lesions.

Pain in different methods of breast biopsy: emphasis on vacuum-assisted breast biopsy.

This study examines pain (visual analog scale 0-10) in women undergoing breast biopsy. Two hundred and twenty-seven patients with a palpable lesion underwent FNA (21G, n=85), core biopsy (14G, n=86) or open biopsy under local anesthesia (n=56). One hundred and twenty-six women presented with a non-palpable lesion, and underwent vacuum-assisted breast biopsy (VABB, 11G) under mammographic guidance, prone position (n=72) or hook-wire localization followed by open surgery (n=54). The techniques sampling non-palpable lesions were the most painful: hook-wire (9.15+/-0.74) and VABB (4.35+/-1.70). Larger needle diameter was associated with more intense pain. Concerning VABB, an S-shape curve of pain (third-order pattern) was documented. A second dose of lidocaine just before the rapid increase phase was then adopted (n=61), and reduced the total/maximum pain. In conclusion, although VABB is less painful than hook-wire, the pain experienced in VABB is significant; however, it can be attenuated by a second dose of lidocaine.

Vacuum-assisted breast biopsy: the value and limitations of cores with microcalcifications.

The aim of this study was to assess cores with microcalcifications (CM) and without microcalcifications (CWM) obtained from vacuum-assisted breast biopsy (VABB). The study included 12 atypical ductal hyperplasias (ADH), 37 ductal carcinomas in situ (DCIS), and seven invasive ductal carcinomas (IDC) diagnosed by VABB (11G) on the Fischer's table. More than 24 cores were excised. For CM/CWM, a separate pathology report was given. Open surgery followed, and underestimation was calculated. The CM/CWM discrepancy was evaluated (superiority, identity, and inferiority). CWM failed to make the diagnosis in 8.3% and 35.1% of ADH and DCIS, respectively. In 28.6% of IDC, diagnosis was made through CWM. CM volume was 1.2+/-0.3 cm(3) for the two IDCs missed by CM, 1.0+/-0.4 cm(3) for the 40 cases of identical diagnoses, and 1.4+/-0.5 cm(3) for the 14 cases of CM superiority (p=0.048, Kruskal-Wallis test). CWM volume was 6.3+/-1.8 cm(3) for the two IDCs missed by CM, 2.6+/-1.8 cm(3) for cases with identical diagnoses, and 3.4+/-1.6 cm(3) for cases of CM superiority (p=0.018, Kruskal-Wallis test). The underestimation rate was 8.3% in ADH, and 10.8% in DCIS. CMs are superior in DCIS/ADH diagnosis. However, CWM may be valuable for the diagnosis of the invasive component.

Is zero underestimation feasible? Extended Vacuum-Assisted Breast Biopsy in solid lesions - a blind study.

BACKGROUND: Vacuum-Assisted Breast Biopsy (VABB) is effective for the preoperative diagnosis of non-palpable mammographic solid lesions. The main disadvantage is underestimation, which might render the management of atypical ductal hyperplasia (ADH), and ductal carcinoma in situ (DCIS) difficult. This study aims to develop and assess a modified way of performing VABB. PATIENTS AND METHODS: A total of 107 women with non-palpable mammographic breast solid tumors BI-RADS 3 and 4 underwent VABB with 11G, on the stereotactic Fischer's table. 54 women were allocated to the recommended protocol and 24 cores were obtained according to the consensus meeting in Nordesterdt (1 offset-main target in the middle of the lesion and one offset inside). 53 women were randomly allocated to the extended protocol and 96 cores were excised (one offset-main target in the middle of the lesion and 7 peripheral offsets). A preoperative diagnosis was established. Women with a preoperative diagnosis of precursor/preinvasive/invasive lesion underwent open surgery. A second pathologist, blind to the preoperative results and to the protocol made the postoperative diagnosis. The percentage of the surface excised via VABB was retrospectively calculated on the mammogram. The discrepancy between preoperative and postoperative diagnoses along with the protocol adopted and the volume removed were evaluated by Fisher's exact test and Mann-Whitney-Wilcoxon test, respectively. RESULTS: Irrespectively of the protocol adopted, 82.2% of the lesions were benign. 14.0% of the lesions were malignancies (5.1% of BI-RADS 3, 5.3% of BI-RADS 4A, 25% of BI-RADS 4B, and 83.3% of BI-RADS 4C lesions). 3.7% of the biopsies were precursor lesions. There was no evidence of underestimation in either protocols. In the standard protocol, the preoperative/postoperative diagnoses were identical. In the extended protocol, the postoperative diagnosis was less severe than the preoperative in 55.5% of cases (55.5% vs. 0%, p = 0.029), and preoperative ADH was totally removed. The phenomenon of discrepancy between diagnoses was associated with larger volume removed (8.20 +/- 1.10 vs. 3.32 +/- 3.50 cm3, p = 0.037) and higher removed percentage of the lesion (97.83 +/- 4.86% vs. 74.34 +/- 23.43%, p = 0.024) CONCLUSION: The extended protocol seems to totally excise precursor lesions, with minimal underestimation. This might possibly point to a modified management of ADH lesions.

A huge posteromedial mediastinal cyst complicated with vertebral dislodgment.

BACKGROUND: Mediastinal cysts compromise almost 20% of all mediastinal masses with bronchogenic subtype accounting for 60% of all cystic lesions. Although compression of adjoining soft tissues is usual, spinal complications and neurological symptoms are outmost rare and tend to characterize almost exclusively the neuroenteric cysts. CASE PRESENTATION: A young patient with intermittent, dull pain in his back and free medical history presented in the orthopaedic department of our hospital. There, the initial clinical and radiologic evaluation revealed a mediastinal mass and the patient was referred to the thoracic surgery department for further exploration. The following computed tomography (CT) and magnetic resonance imaging (MRI) shown a huge mediastinal cyst compressing the T4-T6 vertebral bodies. The neurological symptoms of the patient were attributed to this specific pathology due to the complete agreement between the location of the cyst and the nervous rule area of the compressed thoracic vertebrae. Despite our strongly suggestions for surgery the patient denied any treatment. CONCLUSION: In controversy with the common faith that the spine plays the role of the natural barrier to the further expansion of cystic lesions, our case clearly indicates that, exceptionally, mediastinal cysts may cause severe vertebral complications. Therefore, early excision should be considered especially in young patients or where close follow up is uncertain.

Spontaneous rupture of the colon sigmoid following spontaneous recurrent pneumothorax in a patient with Marfan syndrome.

BACKGROUND: Spontaneous ruptures of the colon and rectum are very rare clinical entities and always require laparotomy. In such cases, despite meticulous exploration an underlying pathology cannot be revealed and most reports in the world literature relate spontaneous colon ruptures with unusual connective tissue disorders such as Marfan or Ehlers-Danlos syndrome. Connective tissue diseases affect the structure and the synthesis of elastin and type III collagen, resulting in various systemic disorders. Among the several pulmonary manifestations, spontaneous pneumothorax is observed in about 5% of patients expressing one of the above syndromes. CASE REPORT: In the following report we present a unique case of spontaneous rupture of the sigmoid colon secondary to spontaneous recurrent contralateral pneumothorax. CONCLUSIONS: The aim of this presentation is to raise the level of suspicion in every surgeon and gastroenterologist to include connective tissue disorders in their differential diagnosis in any case of spontaneous colon rupture and, if found, to follow further diagnostic procedures in anticipation of any other visceral complications.

Sigmoid schwannoma: a rare case.

Schwannomas are rare tumors derived from the cells of Schwann that form the neural sheath. When located in the gastrointestinal tract, they constitute together with leiomyoma, leiomyoblastoma, and leiomyosarcoma, the gastrointestinal stromal tumors (GIST). Peripheral nerve sheath tumors represent 2-6% GIST with most common location, the stomach and the small intestine. Schwannomas of the colon and rectum are extremely rare and radical excision with wide margins is mandatory, due to their tendency to recur locally and become malignant, if left untreated. In the present study, we report a rare case of a sigmoid schwannoma, which was successfully treated in our department and reviewed the literature.