Enhanced recovery pathways in colorectal surgery: a consensus paper by the Associazione Chirurghi Ospedalieri Italiani (ACOI) and the PeriOperative Italian Society (POIS).

Enhanced Recovery After Surgery (ERAS) pathway is a multi-disciplinary, patient-centered protocol relying on the implementation of the best evidence-based perioperative practice. In the field of colorectal surgery, the application of ERAS programs is associated with up to 50% reduction of morbidity rates and up to 2.5 days reduction of postoperative hospital stay. However, widespread adoption of ERAS pathways is still yet to come, mainly because of the lack of proper information and communication. Purpose of this paper is to support the diffusion of ERAS pathways through a critical review of the existing evidence by members of the two national societies dealing with ERAS pathways in Italy, the PeriOperative Italian Society (POIS) and the Associazione Italiana Chirurghi Ospedalieri (ACOI), showing the results of a consensus development conference held at Matera, Italy, during the national ACOI Congress on June 10, 2019.

Proregion of Acanthoscelides obtectus cysteine proteinase: a novel peptide with enhanced selectivity toward endogenous enzymes.

Acanthoscelides obtectus is a devastating storage insect pest capable of causing severe bean crop losses. In order to maintain their own development, insect pest larvae feed continuously, synthesizing efficient digestive enzymes. Among them, cysteine proteinases (CPs) are commonly produced as inactive precursors (procysteines), requiring a cleavage of the peptide proregion to become active. The proregion fits tightly into the active site of procysteines, efficiently preventing their activity. In this report, a CP cDNA (cpao) was isolated from A. obtectus midgut larvae. In silico studies indicated that the complete CP sequence contains a hydrophobic signal peptide, a prodomain and a conserved catalytic region. Moreover, the encoding cDNA contains 963bp translating into a 321 residue protein, CPAo, which was expressed in E. coli, fused with thioredoxin. Enzymatic assays using the recombinant protein revealed that the enzyme was catalytically active, being able to cleave the synthetic substrate Z-Phe-Arg-7-AMC. Additionally, this report also focuses the cpao propeptide (PCPAo) subcloning and expression. The expressed propeptide efficiently inhibited CPAo, as well as digestive CP of other bean bruchids. Little or no activity was found against proteolytic enzymes of two other coleopterans: Rhyzopertha dominica and Anthonomus grandis. The data reported here indicate the possibility of endogenous propeptides as a novel strategy on bruchids control, which could be applicable to bean improvement programs.

Pro domain peptide of HGCP-Iv cysteine proteinase inhibits nematode cysteine proteinases

Cysteine proteinases (CPs) are synthesized as zymogens and converted to mature proteinase forms by proteolytic cleavage and release of their pro domain peptides. A cDNA encoding a papain-like CP, called hgcp-Iv, was isolated from a Heterodera glycines J2 cDNA library, expressed and utilized to assess the ability of its propeptide to inhibit proteinase in its active form. The hgcp-Iv cDNA sequence encodes a polypeptide of 374 amino acids with the same domain organization as other cathepsin L-like CPs, including a hydrophobic signal sequence and a pro domain region. HGCP-Iv, produced in Escherichia coli as a fusion protein with thioredoxin, degrades the synthetic peptide benzyloxycarbonyl-Phe-Arg-7-amido-4-methylcoumarin and is inhibited by E-64, a substrate and inhibitor commonly used for functional characterization of CPs. Recombinant propeptides of HGCP-Iv, expressed in E. coli, presented high inhibitory activity in vitro towards its cognate enzyme and proteinase activity of Meloidogyne incognita females, suggesting its usefulness in inhibiting nematode CPs in biological systems. Cysteine proteinases from other species produced no noticeable activity.

Microbiologic profile of intra-abdominal infections at Belo Horizonte, Brazil.

Intra-abdominal infections (IAIs) represent one of the most common clinical problems in hospital practice, especially in surgical areas and centers of intensive care. The treatment of IAIs generally involves the draining of abscesses and empirical antimicrobial therapy. In this study, among 150 patients suffering from IAI, 106 (70.7%) yielded samples that presented microbial growth. Polyinfection was detected in 51.9% of the cases and varied from 2 to 9 distinct microbes per specimen. The overall mean number of micro-organisms isolated per patient was 2.17. Aerobic bacteria (as strict aerobes and facultative anaerobes), strict anaerobic bacteria, and fungi of the genus Candida represented 93.4%, 30.2%, and 13.2% of the cases positive for micro-organisms, respectively. The most common aerobic bacteria were those of the genera Staphylococcus, Escherichia, Proteus, and Streptococcus. Despite the frequent prior use (52%) with antimicrobials of recognized action against strict anaerobes, these micro-organisms constituted 30.9% of the total isolates, and the most frequently found were of the Bacteroides fragilis group and Prevotella species. The high prevalence of anaerobes in the specimens obtained from IAI demonstrates the need to give greater importance to these micro-organisms by making available material and human resources to carry out culture of the anaerobes as part of routine hospital procedures.

[Intestinal occlusion due to a colonic lipoma. Apropos 2 cases]. / Occlusione intestinale da lipoma del colon. A proposito di due casi.

Lipomas occur through the intestinal tract, from the hypopharynx to the rectum, the colon having the highest incidence, where lipomata are the commonest benign neoplasm after adenomata. Nevertheless they are uncommon. CASE REPORT. 1) A 68-year-old man presented as an emergency with abdominal pain associated with bowel obstruction. He had a 2 to 3 month history of intermittent right-sided abdominal pain, constipation spontaneously resolved. At laparotomy there was a mass of the transverse colon, next hepatic flexure. A right hemicolectomy was performed. The patient made an uneventful recovery. Histologic examination showed a lipoma of the submucosal plane. 2) A 65-year-old man presented as an emergency with lower abdominal pain associated with a prolapsed rectal polyp. He had 1 month history of passing fresh blood per rectum. Ap ast colonoscopy revealed a large polypoid lesion in the descending colon. Transanal examination revealed a polypoid lesion with a maximum diameter of 4 cm, acting as an intussuseptum. Transanal polypectomy was performed. At laparotomy there was an intussuseptum of the descending colon into the rectum: a left hemicolectomy was performed. Histology showed the polyp to be a submucosal lipoma. DISCUSSION. Lipomas are the most common benign nonepithelial tumors of the colon. Lipomata of the large bowel are reported as incidental findings in 0.3-0.5% of cases in large series of autopsies. In the wall of the intestine most lie in the submucosal plane, less frequently they are found in the subserosal plane. The commonest site for symptomatic solitary large bowel lipoma is the ascending colon, including the caecum, followed by the transverse colon, including both hepatic and splenic flexure, descending colon, sigmoid colon and rectum. The peak incidence for lipomata of the large bowel is in fifth-sixth decade. Colonic lipomas are generally asymptomatic but occasionally patients may have intermittent crampy abdominal pain secondary to intussusception of a pedunculated lipoma or with intermittent fresh rectal bleeding. On barium enema lipomas appear circular, ovoid, well demarcated, and smooth. A barium enema showing a relatively radiolucent mass, caused by the radiolucency of fat, is suggestive of a lipoma. The water enema, with water as the contrast agent, accentuates the difference in density between a lipoma and surrounding tissues. Another characteristic feature of lipomas on barium enema is said to be their fluctuation in size and shape during the study: "squeeze sign". Lipomas of the large bowel can be seen, however, by colonoscopy. On computerized tomography scan the lipoma has a uniform appearance and density. In expert hands pedunculated and sessile lesions can be removed endoscopically, but often large bowel lipomata are treated on the basis of a presumptive malignant diagnosis with exploratory laparotomy. CONCLUSION. Colonic lipomas, although unusual, continue to present difficulties in the preoperative differentiation between malignant and benign colonic neoplasm. Two cases of colonic lipomas are reported.

[Stomach diverticulum. A case report]. / Diverticolo gastrico. Descrizione di un caso.

The author reports a case of gastric symptomatic diverticulum, not connected to other gastric-biliary-duodenal pathology. The author points out the rarity of diverticulum of the alimentary canal, and points out the symptomatic picture that, in association with a radiologically ascertained diverticulum staunching, represent indications for surgery.

Carcinoma of the urachus. Report of a case.

The authors report a case of urachal carcinoma of a 60 year old woman of particular interest because of the clinical history, biological behavior and histotype. The tumor presented as an umbilical mass of 25 cm which had slowly increased during 20 years without evident clinical signs or infiltration of the peritoneum and abdominal organs. Histologic findings revealed an adenosquamous carcinoma, which represents less than 5% of urachal neoplasms. Surgical excision is the treatment. The prognosis is poor because of regional recurrence and metastases. The authors review the literature analyzing the criteria for differential diagnosis between adenocarcinoma of vesical and of urachal origin.