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Background: Grade III-IV hemorrhoids require surgical treatment. The Milligan Morgan hemorrhoidectomy (MM) - still considered the gold standard - is now flanked by less invasive surgical methods such as Procedure for Prolapse and Hemorroids (PPH) and Transanal Hemorroidal Dearterialization (THD). The authors wanted to compare in a prospective, randomized trial the MM hemorrhoidectomy and the THD in the treatment of grade III-IV hemorrhoids., Materials and Methods: Between January 2010 and March 2013 they were recruited 87 patients with grade III-IV hemorrhoids. All patients did not previously undergo surgical treatment. From the time of recruitment, for a period of six months the patients evaluated the extent of the symptoms of which were suffering expressing in simple and subjective questionare how hemorrhoidal disease accounted on their social life and wellness. After six months of the 52 patients with grade III hemorrhoids 27 were randomly treated with THD and 25 with Milligan Morgan; of 37 grade IV 18 they were treated with THD and 19 with MM. It was evaluated in particular the post-operative pain recovery, the reaching the feeling of wellness (evaluated with a modified VAS scale), the presence of bleeding and soiling. The patients then underwent follow-up to at three months, one year and three years., Results: Grade III-IV hemorrhoids treated with THD showed a more rapid achievement of the wellness with a lower incidence of post-operative pain and faster recovery and return to work activities and social life compared to MM cases. In grade IV hemorrhoids treated with THD or MM these objectives have been reached later compared to grade III. However in cases of grade IV hemorrhoids THD procedure resulted more difficult respect to cases of grade III and there has been an incidence of recurrence at 3 years equal to 15% of cases. In grade IV hemorrhoids treated with MM no recurrence occurred during the three-year follow-up., Conclusions: For grade III hemorrhoids THD technique provides the same results of MM, while for grade IV hemorrhoids we believe that better result can be achieved with MM technique. However, we deem that in cases of grade IV hemorrhoids the choice between THD and MM can be more rationally made on the basis of objective examination with the patient in the operating position and already anesthetized and therefore in complete relaxation., Key Words: Transanal Hemorrhoidal Dearterialization THD, Milligan-Morgan Hemorrhoidectomy, Post-operative Pain, Hemorrhoids.

Background: To date, the use of meshes in repairing abdominal wall defects has brought many advantages, especially in terms of recurrence prevention, but it is not exempt from complications, such as chronic pain, entero-cutaneous fistulas and intestinal obstruction. Here we report a case of intestinal obstruction in a patient with a large umbilical hernia treated laparoscopically by means of a composite polypropylene mesh, six year before., Case Report: A 49-year-old man came to our care with a 3-day history of central and right lower abdominal quadrant pain and a clinical picture of intestinal obstruction. Six years before the patient underwent a laparoscopic intervention to repair his umbilical hernia, with the positioning of a polypropylene coated mesh. Abdominal ultrasonography (US) confirmed the obstruction and demonstrated adhesions between an intestinal loop and the mesh. Intraoperatively, obstruction was confirmed and an intestinal segment had to be resected., Conclusions: Small bowel obstruction is an uncommon but possible late complication after laparoscopic hernia repair with coated polypropylene mesh.

Unlabelled: Tension-free muscle closure is essential in kidney transplantation, both in adult and pediatric patients. Tight muscle closure may lead to renal allograft compartment syndrome either due to compression of the renal parenchyma or due to kinking of the renal vessels. It may also cause kinking of the transplant kidney ureter, wound dehiscence and incisional hernia. Many techniques have been proposed in an attempt to achieve tension-free closure. There is a wrong belief among surgeons that using prosthetic mesh may increase the incidence of infective complications in these immunosuppressed patients. Also, there is fear that one is not able to monitor the renal graft by ultrasound and perform biopsy in the presence of a mesh. Other alternative techniques to mesh closure include subcutaneous placement and intraperitonealization of the kidney transplant. These techniques however, are valuable when mesh closure is unfavorable or contraindicated as in case of a potential source of infection, like a stoma. Abdominal wall fasciotomy can be adjunctive to the various techniques of muscle closure., Key Words: Abdominal mesh closure, Post transplant incisional hernia, Renal transplantation, Renal Allograft Compartment syndrome (RACS).

Background: Anatomic unexpected variations in biliary tree may be discovered during laparoscopic cholecystectomy., Case Report: A 57-year-old man was admitted for abdominal pain, vomiting and mild jaundice. Abdominal ultrasonography revealed a gallbladder containing multiple stones and biliary sludge. All pre-operative investigations showed no anatomical variations in extrahepatic biliary tree. During surgical intervention an accessory extrahepatic duct, connecting the IV segment of the liver to the fundus of gallbladder, was discovered., Conclusions: Pre-operative routine investigations for gall stones diseases may not reveal anatomic variations of biliary tree.

The gut of a healthy adult harbours a myriad of different microbial species. It is estimated that approximately 10 14 are present in total bacterial colony forming units (CFU). Each colony colonizes a specific intestinal tract. In healthy adult, the main control of intestinal bacterial colonization occurs through gastric acidity but also other factors can influence the intestinal microenvironment such as pH, temperature, competition among different bacterial strains, peristalsis, drugs, radiotherapy and much more. Impaired microbial homeostasis leads to an alteration of the permeability of tissue, together with the activation of the intestinal immune system MALT (mucosal associated lymphoid tissue). In this regard we discuss the increasing experimental evidences of the role of commensal microbiota in the activation of specific intestinal immunocompetent cells. The aforementioned micro-environmental changes provide the substrate for the etiopathogenetic outbreak of numerous pathologies of gastro-intestinal tract, such as intestinal chronic inflammation (Crohn's disease and Ulcerative Colitis), together with a miscellany of extra intestinal disorders. This article is an overview of the latest scientific findings about the close causal relationship between intestinal microbial flora and inflammatory bowel diseases or other extra-intestinal diseases; it is also mentioned the possible relationship between mycobacteria and Chron's disease. Finally we analyse the beneficial role of probiotics.

We report a case of a spleen infarction caused by the vascular pedicle torsion. A 25 year-old-man, heterozygous for HbS, presented with severe abdominal pain especially in the left upper quadrant in front and in the back, fever other symptoms related to acute abdomen. First we excluded most common disease (occlusive one and hematologic one) through conform investigation, then we suspected a spleen problem. So we did further investigation with ultrasonography which showed splenomegaly and the spleen looked twisted with its hilum in contact with previous abdominal wall, moreover (here were are as of decreased signal intensity characteristic of splenic infarction under the capsule and some blood in the Douglas pouch. The patient underwent splenectomy urgently. During the intervention we saw a splenomegaly like the ultrasonography showed, moreover there were a long twisted vascular pedicle and many areas of infarctions, some of which had ruptured causing emoperitoneum. The surgical intervention was successful and the clinical spectrum was solved. The splenic infarction might be clinically silent or to represent a surgical emergency. In front a case of acute abdomen, after exclusion of most common etiology, we underline the importance to suspect a spleen suffering, especially vascular one, when (here was no history of trauma. Considering this fact, a simple not invasive examination like ultrasonography is able to confirm this kind of hypothesis and to give soon information to make the surgical choose.

Immunosuppression, although necessary to enable the graft to escape the consequence of immune surveillance carries some risks for the patients. There is an associated increase in neoplasm, opportunistic infections, and end-organ toxicity. In addition, even with excellent patient compliance, rejection (acute and chronic) remain a major limitation that contributes to the loss or decrease in the function of the allograft. New drugs have been added to the armamentarium of immunosuppressive agents to suppress allograft rejection and to rescue graft from cyclosporine-resistant. Most of the immunosuppressive agents in use today are direct at the T lymphocyte, non-specifically inhibiting T-cell activation and proliferation. The authors described here an update of these new immunosuppressive agents and new strategies used in solid organ transplantation.