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Adenomas of the rectum are frequently found during endoscopic examination. We report on our 30 years of experience with the treatment of tubulo-villous adenomas based on histotype. Between 1971 and 2001, 104 villous tumours of the rectum were treated surgically. The patients' average age was 65 years. These were sessile tumours in 69% of cases, pedunculated in 17.5% and flowing tumours in 13.5%. The mean tumour size was 3 cm. They were associated with colon cancer in 15% of cases and with polyadenoma in 10%. They were located in the rectum within 0 to 6 cm of the anal margin in half the cases. These tumours were treated by local excision in 74 cases and by wide excision in 30 cases. The malignant potential of the tumours was 30%, including 10% invasive malignancy. There were no surgical fatalities, but a 6% medical fatality rate was registered. There was a 20% complication rate related to the surgical technique. Twenty patients were lost to follow-up. Out of 84 villous tumours, monitored over a mean survival period of 6.5 years, there were 24 recurrences: 18 underwent endoscopic excision and in 6 cases a wide resection. The various tumour resection techniques and the operative indications of variable difficulty are presented. It would seem, at present, that total resection of the rectum with a colo-anal anastomosis is the best treatment for large flowing villous tumours occupying almost the entire rectum. Thorough preoperative examination and the mastering of various surgical procedures should allow the most suitable choice of treatment for each individual case.

Objective: To report about a case of enterocolic phlebitis, a rare cause of ischemic intestinal necrosis., Results and Conclusions: The patient, a 71 year-old male, presented with signs of acute abdomen. A right hemicolectomy was performed, which revealed a tubulovillous adenoma with high grade dysplasia located in the ascending colon, and a diffuse ischemic colitis. A localized lymphocytic and granulomatous phlebitis was present in the resected colon. The arteries were spared by the inflammatory process. The patient is alive and well 7 years after surgery. The literature concerning enterocolic phlebitis, a peculiar form of localized intestinal vasculitis, is briefly summarized.

Small bowel tumours are rare neoplasms representing just 1% of all the gastrointestal tract lesions. Adenomas are the benign forms which, developing in the duodenum, tend to localize in periampullary region, with high incidence of malignant degeneration. The authors report a case of a fifty-five-years old woman with a periampullary villous adenoma.

Large colonic villous adenomas are benign neoplasms capable of malignant transformation with a higher frequency than other adenomas. Such transformation often requires surgical therapy after endoscopic resection. The aim of the present study was to establish the indications for surgery in a series of 13 cases of large colonic villous adenomas initially submitted to endoscopic resection. The patients (8 males and 5 females; mean age; 62 years) were observed over the period 1993-2000. All endoscopic resections were performed using the piecemeal technique. In 7 cases there were 2 endoscopic sessions and in one case 3; a single case of post-endoscopic bleeding was treated conservatively. In 5 cases, endoscopic resection was deemed not to be radical and these patients were submitted to surgical resection. Histology on the surgical specimens revealed 2 cases of carcinoma (T1 and T2, respectively), confirmation of colonic villous adenoma in 2 cases and the presence of inflammatory tissue in 1 case. Among the patients treated with endoscopic resection alone one death occurred at two years due to lung and systemic metastases probably due to the malignant adenoma. After a review of the literature and on the basis of their own experience, the authors stress the importance of a combined pathological and endoscopic approach to establish when surgery is required.

Background: The rising incidence of colorectal neoplasms, and in particular those localised in the lower rectum is stressed and the therapeutic opportunities offered by the trans-anal resection technique are underlined., Methods: The indispensable conditions for adopting a surgical approach are pointed out. These are identified as the size of the neoplasm, which should not exceed 4 cm, the fixity, site, the polypoid and non-ulcerated nature of the lesion, and the involvement of not more than 1/4 of the circumference of the bowel. Using these inclusion criteria, the authors operated on five patients in the 4th Division of General Surgery at G. Martino Polyclinic in Messina, using trans-anal resection of low rectal neoplasm., Results: No hemorrhagic complications or lesions in the visceral wall occurred. All patients underwent a follow-up of up to 36 months and to date no patient has presented long-term metastasis; local recidivation was observed in one patient after 14 months and this was treated using the trans-anal method., Conclusions: The authors affirm that trans-anal resection may be regarded as the elective treatment of patients with neoplasms confined to the visceral wall and without dissemination; it is palliative in cases where the tumour is larger than 4 cm, with lymph node involvement. But even in this case, and in more advanced situations, this method allows mortality due to occlusive complications to be reduced and ensures a better quality of residual life.

Aims of the Study: 1. To evaluate the feasibility and appropriateness of transverse right minilaparotomy for right colectomy and lymphadenectomy. 2. To identify the clinical advantages, if any, of this access route compared to the more traditional midline incision., Patients: 44 patients with right colon adenocarcinoma undergoing colonic resection via a transverse or midline laparotomy., Methods: The transverse incision starts 1 cm above the umbilicus, running from the midline to the anterior axillary line., Results: 17 (39%) transverse minilaparotomies and 27 (51%) midline laparotomies were performed, respectively. The mean operative time was 107 min for patients with the transverse incision and 157 min. for those with midline laparotomy. Twelve out of 17 patients (70%) with the transverse incision experienced no or only mild pain as against 11 out of 27 patients (41%) with midline laparotomy. Bowel function was slightly faster in the first group of patients, though the difference was not statistically significant. Forty-seven percent of patients with transverse minilaparotomy were discharged within 8 days postoperatively as against 4% with midline laparotomy (P = 0.001). No major complications occurred in the first group, while 2 patients (7%) operated on via the midline laparotomy experienced complications (haemorrhage, deep venous thrombosis)., Conclusion: Although this is a preliminary study in only 44 patients, our results support the idea that transverse minilaparotomy is a less traumatic access route to the right colon, in addition to offering an adequate exposure of the operative field, faster postoperative recovery and a shorter hospital stay. We believe it to be a good alternative to midline laparotomy for right colon surgery.

Background: Personal experience on transanal excision of rectal adenomas without affecting sphincteric function is reported., Methods: From 1985 to 1997, 27 patients suffering from rectal adenomatous polyps underwent surgery; the sites of lesions were within 3 to 10 cm from anal orifice in the whole series; the age of patients ranged from 30 to 81 years. Two different procedures were employed: the Parks' technique and the electroresection by traction flap technique according to Faivre., Results: Any postsurgical complication such as hemorrhage, stenosis or incontinentia occurred; surgical mortality was absent. Histological examination disclosed severe dysplasia as well as in situ carcinoma in 6 patients (22.2%) and malignant polyps in 9 patients (33.3%). Only in a case a palliative excision was performed since the poor general conditions of this patient did not permit a more extended treatment; a local relapse of the tumour associated with liver metastases led the patient to death 22 months after surgery. Three patients were lost to follow-up and 2 patients died because of other causes, 6 and 8 years after surgical excision, respectively., Conclusions: The conclusions are is drawn that either Park's and Faivre's procedures are useful and safe for the surgical treatment of rectal villous polyps extended up to 8-12 cm from anal orifice, in spite of the presence of malignant foci within their mass. These surgical procedures are simple and relatively poor traumatic; for this reason they are more suitable than other transabdominal or abdomino-perineal approaches for older patients and other at risk-patients. It is underlined that the treated patients require a long-term follow-up aimed at the early diagnosis of possible relapses of adenomatosis.

Objective: Our institution's experience with low anterior resection for primary rectal cancer was reviewed to determine cancer treatment results and to identify risk factors for pelvic recurrence., Methods: Ninety-two patients treated for primary rectal cancer between 1986 and 1997 were studied retrospectively. All cases was classified according to Astler-Coller. Median follow up was 46 months., Results: Actuarial 5-year survival for all patients was 79%. Among 28 patients who relapsed, only 9 pelvic recurrence was detected with an actuarial rate of 15% at 5 years. Lymph nodes involvement were associated with increased risk for pelvic recurrence., Discussion: Low anterior resection permitted by circular stapler provides good treatment for mid-rectal cancers and for some distal rectal cancers. Pelvic recurrence is not correlated with neoplasm localization, T stage and short distal resection margins, but only with the presence of lymph nodes involvement. This result increase the value of the hypothesis that search the pelvic recurrence origin in a extra-parietal disease respect anastomotic disease., Conclusion: Fundamental to prevent pelvic recurrence is the surgical technique that have to remove lymph node en bloc with the rectum doing a dissection along the endopelvic fascia to Denonvillers fascia so to take away completely the mesorectum.

The authors report their experience of the posterior rectal access route. They used this route to operate 7 patients with rectal carcinoma during the period February 1989-October 1994; 3 patients were affected by villous adenoma, 3 by adenocarcinoma, and 1 by pelvic recidivation. Of the 3 patients suffering from adenocarcinoma, two underwent palliative treatment owing to their poor general conditions and the systemic nature of the base pathology, consisting in the exeresis of the tumour using a posterior route. The third patient was treated using a combined abdominal-posterior route; the site of the tumour and the presence of a narrow pelvis would in fact have made an "ultra low" front resection highly risky, whereas coloanal anastomosis (pull through) might have jeopardized efficacious anal continence. On the basis of their experience the authors indicate the posterior access route as a therapeutic possibility in the treatment of medium-low rectal tumours at an early or very advanced stage. The posterior approach is only justified in other forms if combined with laparotomic access. An oncologically correct operation is therefore guaranteed in full respect of sphincteric function.

In this study we tested the hypothesis that colorectal cancers containing adenoma (CCA) could be a different entity from colon cancers without adenoma (CSA). Clinical data, histologic preparations of operative specimens and survival of 210 patients who underwent resective surgery for colorectal cancer were studied. Adenomatous tissue within the cancer was found in 62 of 210 carcinomas (CCA), the other 148 cancers were lacking adenomatous features (CSA). CCA occurred more frequently in female patients (p = 0.003). Synchronous adenomas were detected in the resected colon of 19 out 62 CCA and of 24 out 148 CSA (p = 0.04). CCA showed the extent of intraparietal spread (p = 0.001), grade (p = 0.007) and stage (p = 0.004) lower than CSA. These characteristics also appeared statistically related to size of the cancers. The adenomatous tissue within CCA was tubular in 4 cases, tubulo-villous in 34 and villous in 24 cases. The villous histotype was statistically related to the older age of patients (p < 0.0001), larger cancer size (p = 0.01), presence of synchronous adenomas in the resected colon (p = 0.02) and higher histologic grade of the cancer (p < 0.05). Patients with CCA evidenced a higher 5-year survival rate (p = 0.02). Our results evidence epidemiologic, clinical and pathologic differences between CCA and CSA and suggest a possible double histogenesis of colon cancer.

In patients affected by aortoiliac aneurysm the concurrent presence of a gastrointestinal tumor is a not infrequent occurrence which poses problems of therapeutic approach (one step operation or prior treatment of one of the two diseases; in the latter case definition of timing and sequence of the surgical treatment). Three cases are reported where an eclectic therapeutic approach has enabled satisfactory results. A patient with an isolated aneurysm of right hypogastric artery associated with rectal cancer was treated with percutaneous embolization of the aneurysm and subsequent excision of the tumor. In a patient with a neoplasm of the left colon and aortic aneurysm, the aneurysm was treated first and after about a month the tumor was resected. In a patient with gastric cancer and aortic aneurysm subtotal gastrectomy was first performed and subsequently, after about 3 months, the aneurysm was treated by extraperitoneal route. Even if an unidirectional approach cannot be defined, it is thought that the two-step treatment of the associated diseases is preferable. In the presence of non stenosed non bleeding colorectal tumors it seems more suitable to treat the aneurysm first (increased postoperative risk for rupture of the aneurysm; more difficult preparation of subrenal aorta in the presence of cicatricial outcomes of colonic surgery; persistence of perianastomotic infections after colonic resection). Gastric tumors should be treated first for their higher biological aggressiveness and unfeasible correct preoperative staging. In particular cases (single unilateral aneurysm of a hypogastric artery associated with gastrointestinal cancer), non surgical treatment of the vascular lesion (embolization during angiography) is the treatment of choice.

The Authors note the limits and the more rational directions of using the several tumour markers that they utilized in the study of the neoplastic pathology of the anus-rectum. They particularly point out the benefit as "dynamic indices" of variation of the tumor mass during the neoplasm's progress and treatment. For these neoplasies any new marker offers advantages of diagnostic accuracy and a greater specificity more CEA. Nevertheless other markers used appear interesting as biochemical parameters for tumour growth. The study and the tumour marker's development supported, in recent years, the introduction of new diagnostic methods that include the utilization of monoclonal localization of the tumour mass.