[Diagnostic and therapeutic guidelines for entero-cutaneous fistulas. Personal experience and literature review]. / Orientamenti diagnostico-terapeutici nel trattamento delle fistole enterocutanee: esperienza personale e review della letteratura.

The entero-cutaneous fistulas (ECF) are abnormal communications between intestine and abdominal skin. They can occur spontaneously, or after an injury or a surgical procedure. They are associated with a high rate of morbidity and mortality. Spontaneous fistulas can mainly occur in patients affected by cancer, inflammatory bowel disease, diverticulitis, appendicitis, as a result of radiotherapy or injuries. Surgical procedures, carried out in case of neoplastic diseases, inflammatory bowel disease, adhesions removal, represent the primary cause in the development of a postoperative fistulas. Malnourishment, poor general conditions of the patient, high output fistula along with anatomical site of development, and the presence of abscesses, represent the negative factors influencing the spontaneous healing of fistulas. The experience reported here is about three ECF cases occurred after surgery and treated only with medical therapy. The first case is a woman in good general conditions who underwent surgery to remove a recurrent retroperitoneal myxoid liposarcoma situated in the right lower quadrant. The patient had never undergone surgery for an intestinal resection. The other two patients analyzed were affected by sepsis and metabolic unbalance and had developed a fistula after colonic resection. Fluids and electrolytes adjustments and sepsis management have preceded any other kind of therapy. Continuous infusion with somatostatin, fast, proton pump inhibitors and loperamide have been taken up to decrease secretions and intestinal motility. Total parenteral nutrition has been essential to recover nutritional status and improve patients' general conditions. In order to heal and protect peri-fistula skin we have used sterile washing solutions, absorbable ionic exchange resin, silver and polyurethanes based medications and colostomy bags adhesive systems. Since surgical treatment of ECF is associated with high rates of morbidity and mortality, conservative treatment should always be taken into consideration. When conservative treatment fails, delayed surgical intervention has been related to a higher rate of success. The purpose of this study is to describe diagnostic and therapeutic guidelines to general surgeons, like ourselves, whenever they have to deal with ECF cases.

[The gold standard in the treatment of haemorrhoidal disease. Milligan-Morgan haemorrhoidectomy vs Longo mucoprolapsectomy: comparing techniques]. / Il gold standard nel trattamento della malattia emorroidaria. Emorroidectomia secondo Milligan-Morgan vs mucoprolassectomia secondo Longo. Tecniche a confronto.

AIM: Although mucosectomy according to Longo was a real revolution in the treatment of haemorrhoidal disease, Milligan-Morgan haemorrhoidectomy, maintaining the characteristics of a technique which is physiopathologically efficacious and easily performed, is still the procedure of choice in some clinical conditions. The aim of this study was to evaluate which of the two techniques, Milligan-Morgan haemorrhoidectomy and Longo mucoprolapsectomy, could be considered the gold standard in the treatment of haemorrhoidal disease. METHODS: From March 2002 to October 2006, in the VII Department of General Surgery of SUN, we compared two groups of 26 patients each: one treated with Milligan-Morgan haemorrhoidectomy, the other one with Longo mucoprolapsectomy. Among the patients treated with traditional technique, 16 were suffering from grade III haemorrhoids and prolapse, while the other 10 from grade IV haemorrhoids and prolapse. The group treated with stapler was composed of 10 patients affected by grade III haemorrhoids and prolapse, while the other 16 were patients complaining for grade IV haemorrhoids and prolapse. For both groups of patients the follow-up lasted 12 months; they were controlled at 1 week, 1 month, 6 months and 1 year after the operation. RESULTS: The level of pain measured with a visual analogue scale (VAS) was always higher in the group treated with traditional technique. In 69% of the patients treated with stapler and in 59% of those treated with open technique there was the first defecation within postoperative day 2. The return to normal activity was earlier in patients who underwent Longo technique. Among the patients treated with traditional technique, 7.7% had postoperative bleeding, 15.4% at the 6-month control, suffered from anal fissure with associated high pressure of anal sphincter and tenesmus and 7.7% showed a recurrence after 1 year. In the group treated with Longo technique, 11.54% of the patients had a postoperative haemorrhage at the 6-month control, 7.7% showed substenosis, 3.84% of the patients felt tenesmus; in 3.84% of the cases a perianal extra-sphincteric fistula was evident. At 1 year control, 11.54% of the patients showed recurrences. CONCLUSION: The conclusion is drawn that it does not exist any indication for the Longo technique; however, it seems to give the best results in grade III haemorrhoids with prolapse, without sphincteric implications.

[Diagnosis and treatment of gallbladder and common bile duct stones: our experience]. / Diagnosi e trattamento della calcolosi colecisto-coledocica. Nostra esperienza.

AIM: The aim of this study was to verify the possibility to identify and treat common bile duct (CBD) stones by means of preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) with a reduction of postoperative complications. METHODS: We have carried out a retrospective monocenter analysis of 104 consecutive patients who underwent a laparoscopic or open cholecystectomy performed by a single surgeon at the VII Division of General Surgery, Second University of Naples, between 2002 and 2006. Before the operation, we have performed highly selective studies like MRCP and ERCP to identify and treat CBD stones in patients affected by pancreatitis, jaundice, high liver function tests or in case of common bile duct dilation at the US examination, without intraoperative cholangiography. RESULTS: Of 104 patients with indication for a cholecystectomy, 22 patients (21.2%) presented high levels of cholestasis tests; 13 patients (12.5%) presented common bile duct dilation at the US examination (>6 mm diameter). Both groups underwent a MRCP which was positive in 8 patients (7.7%), confirming the diagnosis of common bile duct stones. For these reasons we removed CBD stones using preoperative ERCP. CONCLUSION: Preoperative ERCP and RMCP, without intraoperative cholangiography, is not associated with a significant increase in morbility/mortality associated with CBD stones before surgical treatment.

[Minilaparotomy versus laparoscopy in the treatment of cholelithiasis: our experience]. / Minilaparotomia versus laparoscopia nel trattamento della litiasi biliare: nostra esperienza.

The traditional biliary surgery has undergone some transformations to patient's advantage. Nowadays the open-surgery of cholelithiasis is inclined to reduce the incision to 5-6 cm and to perform a transverse one to respect the anatomy of abdominal wall. From July 2002 to April 2006, 82 cholecystectomy (53 minilaparotomy cholecystectomy, and 29 laparoscopic cholecystectomy) have been performed in our institution. The two groups are homogeneous for age, sex, BMI, ASA. Among the patients who underwent a minilaparotomy cholecystectomy we observed a quick recovery of normal activities already 24 hours from the operation, a hospital stay of 24-48 hours and an excellent esthetic result. The minilaparotomy approach is, in our opinion, similar to laparoscopic for short and long time results. Nevertheless, according to medical literature, our first choice is for laparoscopic approach and we prefer laparotomy approach in selected clinical conditions.

[Anastomotic configuration as a risk factor in the recurring onset after intestinal resection for Crohn's disease: our point of view]. / La configurazione anastomotica quale fattore di rischio nell'insorgenza di recidiva dopo resezione intestinale per morbo di Crohn: nostro punto di vista.

Crohn's disease is an inflammatory chronic intestinal disease characterized of an high level of postoperative recurrence. Actually surgical treatment is not decisive; patients can undergo several operations during their lives, running the risk of coming up against the syndrome of short bowel. The main disease frequently appears in the segment ileo-caecal, while the site more often affected by the recurrence seems to be the stump close to the anastomosis. General, local and not specific factors should influence the recurrence level. Among the general factors, cigarette smoking would have a leading role in the recurrences onset. Giving up smoking and a treatment with 5-ASA (amino-salicylic acid) help to reduce the risk of Crohn's recurrences after surgery. During the treatment of this pathology the wide intestinal resections are not justified because the anastomotic recurrence after resection seems to be influenced not by the presence of remaining lesions but by the type of realized anastomosis. Although they disagree about the type of anastomosis to adopt, the authors agree identifying the anastomotic stenosis as the main factor which determines the recurrences. Stenosis, in fact, determining fecal stasis and, therefore, the increase of the pressure at the intestinal wall level, causes ischemia of this same wall. Ischemia puts up the risk of fistulas and anastomotic dehiscence. The mechanical or manual ileo-colic side-to-side anastomosis, assuring a wide lumen, drops to the minimum the risk of stenosis compared with the end-to-end and end-to-side configurations. And then, the side-to-side ileo-colic anastomosis avoiding the intestinal compartmentation between ileo and colon, guarantees less reflow in the small bowel of bacteria and colic metabolite. In this way the inflammatory process which brings to the fresh outbreak of the disease on the mucosa of the near anastomotic head faints. In the light of this thesis, most of the authors, including the writer, agree about making the side-to-side anastomoses in the intestinal resections for the Crohn's disease.

Carcinoid of the vermiform appendix. Description of three clinical cases and review of the literature.

Carcinoids of the appendix represent a separate class of tumours with characteristics that vary between benign (adenomas) and malignant (carcinomas) neoplasias. A recent nomenclature identifies them as diffuse neuroendocrine system (DNS) and/or, parallely, as neuroendocrine tumours (NET): the gastroenteric tract is the site of about 64.3% of carcinoids, followed by the respiratory tract with 25.3%. Among the gastrointestinals, tumour of the small intestine is the one with the highest incidence with 28.5%, followed by the appendix with 4.77%, the rectum with 13.6% and the stomach with 4.6%. Carcinoid of the colon has an incidence of 8.62%, with the caecum which alone represents 34.5% of colic localisations. The 3 cases described are an example of the behavioural unpredictability of intestinal carcinoids. The first case is that of a female patient in whom the primary tumour was only discovered after liver metastasis was documented. The second case regards a girl who, at admission, presented a picture of acute abdomen with the symptomatological characteristics of acute appendicitis. She was submitted to an appendicectomy. Subsequent investigations carried out in the postoperative period documented the presence of liver metastasis at the V and VI liver segments. The last case, similar to the second from certain points of view, shows the need to carry out a right hemicolectomy with removal of locoregional lymphnodes in the event of an appendicular carcinoid >2 cm. Both laboratory and instrumental examinations contribute to the diagnosis of intestinal carcinoid. The main laboratory examinations are based on the measurement of serotonin and urinary 5-hydroxy-indolacetic acid. First level instrumental examinations for the diagnosis of intestinal carcinoid are represented by CT with and without contrast medium, diagnostic endoscopy and, to better highlight the presence of locoregional metastases, scintigraphy with octreotide and PET. An alternative treatment of liver metastases other than surgery is most certainly chemoembolisation. This latter treatment has also proved very effective as a neoadjuvant treatment for liver metastases before subjecting the patient to liver resection. Treatment with somatostatin, on the other hand, proved effective in controlling tumour secretion, so attenuating the inconveniences of carcinoid syndrome.

[Nearly total thyroidectomy: versus total thyroidectomy: our experience]. / Tiroidectomia quasi totale versus tiroidectomia totale. Nostra esperienza.

AIM: Generally, the classification of thyroidectomy as benign pathology is: multinodular toxic goitre, simple goitre, toxic adenoma, Base-dow disease, Hashimoto's tyroiditis Subtotal thyroidectomy provides for the removal of the gland except for a bilateral residue of about 6-10 g, near total thyroidectomy provides for the near total removal of the gland except for a residue inferior to 5 grams. Near total thyroidectomy has taken the place of the subtotal thyroidectomy. METHODS: In two years, in our institute, there have been exeuted: 96 near total thyrodectomies, 96 total thyroidetomies, 8 lobectomies ad two revues for recurrencies. RESULTS: In 2 cases there have been haemorrhagies after nearly total thyroidetomy. Only in 1 case we practiced tracheotomy for follicular carcinoma infiltering thiroidic cartilage. In 2 cases treated with nearly total thyroidetomy and in 4 cases treated with total thyroidetomy, there has been temporary hypoparathyroidism. In no case treared wih nearly total thyroidetomy and in 2 cases treated with total thyroidetomy, there has been permanent hypo-parathyroidism. In 5 cases treated with total thyroidetomy and in no case treated with nearly total thyroidetomy, there has been, monolateral, temporary paralysis of the inferior laryngeal nerve that solved in 6 months for 3 patients and in 2 months for 2 patients. CONCLUSIONS: There has not been permanent paralysis of the mono or bilateral inferior laryngeal nerve. Even if the surgical approach to the benign disease is now orientated to the total thyroidectomy, a more conservative surgery is, in our opinion, justified when a malignant pathology is excluded and considering also the low effect of recurrencies and hypothyroidism.

Regulation of experimental autoimmune encephalomyelitis: inhibition of adoptive experimental autoimmune encephalomyelitis by 'recovery-associated suppressor cells'.

We have previously shown the presence of suppressor cells in Lewis rats at the time of spontaneous recovery from experimental autoimmune encephalomyelitis (EAE). These cells, called 'recovery-associated suppressor cells' (RASC), are capable of preventing active EAE and inhibiting in vitro the specific proliferative response of encephalitogenic anti-MBP T cell line cells. The present investigations were undertaken in order to lend support to the hypothesis that RASC play an active role in the recovery. We found that RASC can prevent adoptive EAE when admixed with already activated, but not resting, anti-MBP T cells or when injected into the recipients separately from the encephalitogenic cells. They can also arrest the course of an ongoing disease when injected after the beginning of the clinical signs. This study provides the first direct demonstration of the downregulation of an ongoing EAE by suppressor cells.

Pathogenic and non-pathogenic T lymphocytes specific for the encephalitogenic epitope of myelin basic protein: functional characteristics and vaccination properties.

Activated CD4+ T lymphocytes specific for myelin basic protein (MBP) can cause experimental autoimmune encephalomyelitis (EAE) upon their inoculation into syngeneic recipients. In Lewis rats, most of the pathogenic T cell clones that develop following immunization with MBP are reactive against the 72-84 amino acid sequence of MBP, the major encephalitogenic region for Lewis rats. In this study, some MBP-specific T cell clones were found to be non-pathogenic, in spite of their strong reactivity against the encephalitogenic epitope. One of these non-pathogenic clones, designated Znp, and an encephalitogenic clone, Z1a-p, were derived from Z1a encephalitogenic line cells. These subclones were compared for epitope specificity, T cell receptor variable gene expression and for various functional activities, in order to delineate properties crucial for pathogenicity. The Z1a-p and Znp cells expressed comparable levels of the T cell receptor genes and shared strong reactivity against the 72-84 epitope of MBP. The pathogenic Z1a-p cells displayed MBP-specific cytolytic activity in vitro, provided an in-vivo 'help' for elicitation of MBP-specific antibodies, mediated a delayed type hypersensitivity (DTH) response to MBP, caused EAE and vaccinated against the disease, thus demonstrating that a single CD4+ T cell clone is capable of eliciting various functions. The non-pathogenic Znp cells could also carry out most of these various functions, but failed to mediate a DTH response to MBP in normal animals. However, when inoculated into sublethally (650 R) irradiated syngeneic recipients, the Znp cells became highly pathogenic and mediated DTH response to MBP. Local irradiation of the recipient facilitated a DTH response to MBP in the irradiated ear, indicating that Znp cells are equipped with the effector mechanisms required for pathogenicity, and that their failure to cause disease may be accounted for by their inability to migrate into extravascular target tissue. Similar data were obtained with an independently isolated non-pathogenic clone, LB-3, specific for the encephalitogenic epitope of MBP. The ability of these non-pathogenic cells to vaccinate against EAE mediated by pathogenic cells raises the possibility that such non-pathogenic cells may play a role in triggering downregulation of pathogenic T cells.

Regulation of experimental autoimmune encephalomyelitis. Specificity of the 'recovery-associated' suppressor cells.

We previously reported the presence of suppressor cells in Lewis rats at the very time of spontaneous recovery from experimental autoimmune encephalomyelitis. As these 'recovery-associated' suppressor cells might be implicated in the self-cure process, we investigated their specificity on the in vitro lymphoproliferative responses of a T cell line specific for myelin basic protein (MBP). We report now that these suppressor cells found in the thymus are specific for MBP, and not for T cell receptors, contrasting with the 'post-recovery' suppressor cell specificity reported by others. Furthermore, they do not recognize the encephalitogenic peptide 71-84, suggesting that their specificity involves an epitope outside (or partially out of) the encephalitogenic sequence.

[Experimental autoimmune encephalomyelitis: immunoregulation and genetic control]. / Encéphalomyélite autoimmune expérimentale (EAE): immunorégulation et contrôle génétique.

EAE is a good model of autoimmune diseases and an approximate one of MS, particularly in its chronic recurrent and demyelinating forms. The antigenic target of EAE has recently been better defined: in different species, as well as within a given one, the encephalitogenic determinant, target of T effector cells, is located in different parts of the basic protein of myelin. The recognition of the relevant epitope is influenced by the genotype of the antigen presenting cells. By analogy, in MS, one can expect to find various target-antigens for the immune (autoimmune?) reactions that occur in the Central Nervous System of different patients, may be in correlation with HLA phenotype. The study of immunoregulatory processes in EAE suggests a possible role for suppressor cells and for variations in the capacity of interleukin-2 production. Similarly, in MS, variations in suppressor cell activities have been found in acute attacks. Finally, the possibility of "vaccinating" against EAE with attenuated encephalitogenic line cells, opens new interesting perspectives in the therapy of MS.

Suppressor cells in Lewis rats with experimental allergic encephalomyelitis: prevention of the disease and inhibition of lymphocyte proliferation by the suppressor cells or their products.

Lewis rats primed with myelin basic protein (MBP) in complete Freund's adjuvant develop experimental allergic encephalomyelitis (EAE) and suddenly recover 15 to 17 days later. It was previously found that nondraining lymph node (non-DLN) cells taken at the time of convalescence and transferred into syngeneic normal animals inhibit the subsequent induction of EAE. In this report, it is shown that a suppressive factor can be extracted from non-DLN cells which mimics the inhibitory effect of cells when injected into the recipients. Non-DLN cells keep their suppressive activity on the induction of EAE after a culture of 48 h but their supernatant of culture failed to exert any protective effect in vivo. However, in vitro both the culture supernatant and the suppressor cells were found to have an inhibitory effect on the proliferative response of immune lymphoid cells to the antigen (MBP).