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The Authors discuss on a laparoscopic-assisted approach for excision of a sessile villous adenomatous polyp of the cecum, unresectable by endoscopy. Because of the large implant of the polyp, endoscopic polypectomy was considered at high risk and a surgical laparoscopic procedure was scheduled for removal of the lesion. After right colon mobilization, an intraoperative endoscopy confirmed the location of th polyp in the posterior wall of the cecum, closed to the ileo-cecal valve. A small 10 cm laparotomy, through which the cecum was pulled out the abdominal cavity, was performed. Then, a minimal colotomy along the intestinal taenia was carried out to allow a safe and complete excision of the polyp. This laparoscopic approach differs from the other laparoscopic-assisted methods reported in the Literature since it provides at the same time the postoperative advantages associated with minimal access surgery and a safe oncological removal of the polyp with low risks of complications.

Venous thromboembolism (VTE) is a frequent complication in patients undergoing major surgery, with the possibility of long-term disability or fatal outcome. The rationale of the thromboprophylaxis in all patients can be summarized in three points: 1) the VTE is common in some types of surgery; 2) the VTE can be fatal; 3) thromboprophylaxis is highly effective and safe and, besides these clinical benefits, leads to lower total costs of treatment without further diagnostic and a new shelter for treating venous thrombosis. The surgical patients may present at admission one or more risk factors for VTE, The effect of this risk is cumulative, it is important to stratify the risk and to established an adequate prophylactic strategy. Today there is a unanimous consensus that the low molecular weight heparins are both effective and safe in preventing VTE in surgical patients. Unanimously approved guidelines can help surgeons in making decisions regarding VTE prophylaxis.

The control of the spread of hepatitis B virus (HBV) infection within dialysis units has been an important goal in the management of patients on regular dialysis but infected patients continue to enter the dialysis system. It is evident that HBV viraemia in hepatitis B surface antigen (HBsAg)-positive patients on dialysis is low but it remains unclear whether haemodialysis per se can contribute to viral load reduction in such patients. HBV DNA was determined in 40 HBsAg-positive patients on maintenance haemodialysis immediately before and at the end of a 4-h haemodialysis session. The same measurements were repeated 48 and 72 h later. Twenty (50%) of 40 HBsAg-positive patients had detectable HBV DNA in serum. Detectable HBV DNA in serum was not predicted by demographic, clinical or biochemical parameters. HBV load decreased in the majority of patients after haemodialysis, although the difference was not significant (29 390 +/- 48 820 vs 23 862.8 +/- 4 350 copies/mL, NS). There was a strong relationship between mean HBV DNA levels before dialysis and absolute reduction of HBV DNA during haemodialysis sessions (r = 0.75, P = 0.0001). No difference occurred in the magnitude of change in HBV DNA titre when comparing cellulosic to synthetic membranes. Haemodialysis per se leads to a reduction in HBV load in HBsAg-chronic carriers on maintenance dialysis. This phenomenon could explain the low viral loads in these patients. Prospective studies are in progress to identify the mechanisms responsible for reduction in HBV load during haemodialysis.

Adrenal myelolipoma is a rare benign, non-functioning tumor consisting of fat and hematopoietic tissues. In January 2005 we had observed an adrenal myelolipoma in 70 year old man. During the follow-up for bladder urothelioma, an abdominal CT revaled a well delineated 4x4 cm homogeneous fatty mass in the right suprarenal area with negative attenuation values. The functional study of adrenal gland was normal. The patient underwent videolaparoscopic right adrenalectomy (Gagner technique). Postoperative course was uneventful. The istological diagnosis showed adrenal myelolipoma. We conclude that videolaparoscopic adrenalectomy should be considered the gold standard treatment for benign adrenal lesions.

Treatment of liver hydatid cyst is still controversial. Besides medical treatment, interventional radiologic techniques and traditional surgery, recently the laparoscopic approach has been proposed. Laparoscopic treatment of liver hydatid cyst, however, has not been well defined so far and seems to be associated with a recurrence rate from 0 to 9%, in a 3-49 months follow-up. Disadvantages of the laparoscopic approach are difficult control of spillage, peritoneal dissemination of parasites and incomplete aspiration of high density fluid contents of the cyst. The authors have reviewed the literature and describe a personal technique to avoid this disadvantage and to reduce postoperative recurrence rate.

Control of spread of HBV infection in dialysis units in developed countries has been one of the major advances in managing end-stage renal disease (ESRD). Patients with chronic HBV, however, continue to enter the population pool of dialysis patients and transplant candidates. The clinical significance related to the presence of HBsAg in serum of dialysis patients has not been completely understood.We collected demographic, biochemical and virological data from a large (n=464) population of patients on maintenance dialysis. This was done to assess the influence of virological and host factors on hepatocellular damage, as shown by serum aminotransferase activity.The frequency of HBsAg positivity in our dialysis population was 8.2 % (38/464); the rate of HBsAg positive patients showing HBe antigen was 20.6% (7/34). Twenty-two (84.6%) of 26 HBsAg positive patients showed detectable HBV DNA in serum by Amplicor HBV MonitorTM Test. HBsAg positive patients had serum aminotransferase activity significantly higher than HBsAg negative individuals; GOT (AST) 25.1+/-29.9 vs. 16+/-21.5 UI/L (p=0.001), and GPT (ALT) 31.3+/-52.5 vs. 17.7+/-21.9 UIL (p=0.034). In the subset of HBsAg positive dialysis patients, those in the replicative phase HBeAg positive) had aminotransferase activity higher than HBeAg negative individuals, AST, 42.3+/-43.6 vs. 22.4+/-27.3 UI/L (p=0.097) and ALT, 49.41+/-54.7 vs. 29.17+/-55.76 UI/L (NS) respectively. We did a multivariate analysis by standard least square model on the entire patient group and we found independent and significant association between detectable HBsAg in serum and AST (p=0.0089)and ALT (p=0.0159) values. There was an independent and significant relationship between age and ALT (p=0.01).In our study group, HBsAg positive patients on dialysis had serum aminotransferase activity significantly higher than that measured in HBsAg negative individuals. However, mean transaminase levels in HBsAg positive patients on dialysis were below the upper limit of normal for the reference range of healthy controls. HBsAg positive dialysis patients with active viral replication showed the greatest liver damage. Studies are in progress to understand further HBV-related liver disease in dialysis population.

In this open prospective study the correlation between bleeding patterns and endometrial histology has been evaluated in 101 postmenopausal women after 2 years of continuous sequential hormone replacement therapy (HRT).All patients received continuous transdermal 17-b-estradiol supplementation, 0.05 mg/daily, with cyclic progestogen for 12 days every month. The progestogen was: dydrogesterone 10 mg/daily (56 cases); nomegestrol 5 mg/daily (15 cases); MAP 10 mg/daily (15 cases); norethisterone 0.25 mg/daily (15 cases). The changes in the characteristics of bleeding pattern and endometrial biopsy were performed in 90 of 101 patients, at the 10-12th of progestogen therapy.The endometrial pattern was secretory in 60 cases, proliferative in 5 and atrophic in 22. In 3 cases the endometrial histology showed a simple hyperplasia. The bleeding generally starts 2 days after the end of progestogen therapy (13th +/- 2.9 day), with a mean duration of 4 days (4 +/- 2.8); in 21 patients (~20%) the bleeding is reduced. The endometrial histological characteristics haven't any influence on the bleeding pattern.In this study there was a low incidence of simple hyperplasia (3%), but the characteristics of bleeding don't permit to suspect this hyperplasia.

The Authors describe the evolution of their anesthesiological techniques in the surgical repair of inguinal hernia. In this study they compare indications, complications, costs, hospital stay, length of surgery, postoperative pain and return to work after operations performed under local, spinal and general anesthesia. In their experience inguinal hernia treatment with local anesthesia and a tension-free technique is the preferred method of surgical repair.

The authors report a rare case of stenotic sigmoid endometriosis which presented with constipation and dysmenorrhea in a 48-year-old woman without past gynecological history. There were no typical radiological and endoscopic findings and only pathological examination revealed endometriosis. The patient did well after sigmoid resection and bilateral salpingo-oophorectomy and has had no further complaints. The authors stress the rare location of the disease and review the literature about etiopathogenetic hypotheses and pathological features. The diagnostic value of clinical examination, barium enema and colonoscopy is low as endometriosis rarely involves the mucosa. This case led the authors to discuss about diagnostic difficulties, differential diagnosis and therapeutic options.

The authors report a rare case of mesenteric cyst in a 36 years old woman. These cysts have a pathogenesis that primarily may be ectopic lymphatic tissue and their most common site is in the small bowel mesentery, especially of the ileum. In the case reported the cyst was located in the right mesocolon. Mesenteric cysts can appear as chronic abdominal pain, a painless abdominal mass, or acute abdomen. Diagnostic aids include abdominal computed tomography and sonography, that usually make diagnosis of mesenteric cyst. Treatment of choice is enucleation; resection of the adjacent bowel may occasionally be necessary.

In order to assess the effects and acceptability of transdermal estradiol on the prevention of the loss of bone mass, the Authors administered transdermal estradiol (ETTS 50 mcgr/day) for 3 weeks and, cyclically, medroxyprogesterone 10/mg/day from day 10 to day 21 of each cycle for 12 months, to 20 operated patients for bilateral ovariectomy. Primary markers of the bone turnover (hydroxyproline urinary, osteocalcin, PTH) were estimated before therapy and after 3, 6, 9, 12 months. The BMD was evaluated before therapy and after 6 and 12 months. Our study clearly shows that the transdermal administration of estradiol prevents the postmenopausal bone loss, also in postmenopausal women at higher risk of developing osteoporosis as those evaluated in our study.

The most important factor responsible for osteoporosis postmenopausal is the loss of the oestrogen. For this reason we have estimated the modifications of the bone turnover in the operated patients for bilateral ovariectomy in fertile age by study of the BMD (bone mineral density) and of the various biohumoral parameters that are involved in the process of bone remodelling urinary hydroxyproline, osteocalcin). Our research consists of two phases. I phase: we have conducted a transverse study on a group of 43 patients subdivided in 3 subgroups on the basis of the years elapsed since they were operated. II phase: it is a longitudinal study. We have observed 6 women. We have estimated the turnover before the operation (T0) at (T1), at 30 (T2), at 90 (T3) and at 180 (T4) days from the operation. The results show that the sudden and rapid decrease of the oestrogenic rate determines a sudden increase of the bone turnover. The activity of the osteoblastic line is faster, the activity of osteoblastic line is slower. The beginning of the loss of the bone mass is about the 7% already at six months (longitudinal study), the loss of bone mass reaches the maximum within the first 2-3 years (about 16%) from the operation (transverse study).

Two patients with retroperitoneal liposarcoma are presented to determine the accuracy of diagnostic methods and the role of surgical treatment. In both the patients the large retroperitoneal liposarcoma recurred locally after surgery. Histological features, clinical presentation, diagnostic procedures, extent of surgical resection and adjuvant treatment are reviewed. These data suggest that an aggressive surgical approach followed by adjuvant postoperative irradiation is the treatment of choice in primary and recurrent neoplasms.

After a wide analysis of peptic gastroduodenal ulcer medical therapy, before and after the era of cimetidine, the Authors, after a brief account of the Anatomy and Physiology of the stomach, examine surgical therapy, from the end of the last century till now. After giving the results of the surgical cases of one of them (A. Vinci), including 500 operations, from 1955 till now, almost all with gastric resection, without vagotomy, the Authors point out that today, in the era of cimetidine, surgical therapy has considerably diminished and is reserved only for the complications of pathological cases (perforation, hemorrhage, closed duodenum stenosis), and for those cases which don't respond to antisecretory pharmacological therapy. They also emphasize, that nowadays, in spite of the cooperation among gastroenterologists, gastroscopists and surgeons, the etiopathogenesis of peptic ulcer isn't clear yet, and they conclude by saying that our lack of knowledge of its origin and natural evolution, doesn't guarantee a definitive cure, although the therapy with cimetidine and similar medicines, according to the Authors' personal experiences and opinion, must be continued for the patient's entire life.

The authors report a case they had the opportunity to observe, surgically treated (thoraco-phrenotomy, removal of the herniated mass, repair of the diaphragmatic breach). They illustrate the genesis of such abnormality, its incidence and symptomatology. The Authors, moreover, dwell upon the diagnostic problems caused by Bochdalek's hernia with retroperitoneal contents, and upon the advantages shown by the thoracic way of aggression in the light of their own experience.

On the basis of a study of the most recent clinico-statistical contributions on diverticula of the duodenum and personal experience, based on observation of 72 cases, the Authors set out a modern review of the subject. After emphasizing that diverticula of the duodenum are responsible for clinically evident and uncharacteristics sympatoms in only about 10-20% of cases, the Authors discuss the most modern procedures for diagnosis of diverticula of the duodenum. Lastly there is a full discussion of the indications for operation and the different surgical possibilities for treatment of the disease.

The authors, showing a case of breast retroareolar leiomyoma, study the literature thereabout, and emphasize the rareness of such disease, the impossibility of a correct preoperative diagnosis and the features of absolute benignity of this lesion.

One case of small bowel obstruction due to phytobezoar is reported. The various aetiological factors are discussed. The clinical features are not typical and small bowel obstruction can be initially recurrent until a complete intestinal occlusion. The diagnosis is not easy, and is nearly always made during urgent laparotomy. Surgical treatment consists of phytobezoar removal by enterotomy. The recognition of high-risk patients and their education to prevent phytobezoar are emphasized.

Purpose: To evaluate the fracture risk and survival outcomes in patients with metastatic castration-resistant prostate cancer (mCRPC) who received sequentially abiraterone acetate (AA) and radium 223 [223Ra]RaCl2 in the daily clinical practice. Materials: We retrospectively reviewed the records of mCRPC patients who received [223Ra]RaCl2 immediately after progressing during an AA treatment line in everyday clinical practice. Results: We reviewed data of a consecutive series of 94 mCRPC patients. Most of the patients (85.1%) received [223Ra]RaCl2 as second- or third-line treatment. [223Ra]RaCl2 treatment was well-tolerated; there were only four cases of grade 3 anaemia, two cases of grade 3 leukopenia and one case of grade 3 neutropenia. The overall fracture rate is 2.1%; one fracture was recorded during the course of [223Ra]RaCl2 treatment, and one was recorded 1 month after its end. The fractures both occurred at metastatic sites. Median OS from [223Ra]RaCl2 start was more than 14 months regardless of the treatment line when [223Ra]RaCl2 was administered. Conclusion: The findings of this study show that the treatment with [223Ra]RaCl2 immediately after AA was active and safe with a very low risk of a fracture. Thus, the present observational report makes a valuable contribution to the current debate concerning the risks and benefits of including [223Ra]RaCl2 in the therapeutic algorithm.