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Enterobius Vermicularis (EV) is the most commonly identified heminth incidentally found within the appendix of a clinically diagnosed appendicitis. This simple presence of EV may cause appendicular colic, primarily affecting children, it is an important cause of negative appendicectomy. We report a case of a young male who presented with clinical features of acute appendicitis. Laparoscopic appendicectomy was uneventful and pathologic examination revealed the presence of an EV infestation originating from the lumen of his vermiform appendix. KEY WORDS: Acute appendicitis, Diagnosis, Enterobius Vermicularis.L’Enterobius Vermicularis (EV) è il più frequente ossiuro identificato occasionalmente all’analisi istologica dell’appendice eseguita a seguito di appendicectomia per appendicite acuta diagnosticata clinicamente. La sola presenza dell’EV può portare allo sviluppo di coliche appendicolari, soprattutto nella popolazione pediatrica, determinando l’esecuzione di appendicectomie senza riscontro istologico o intraoperatorio di un quadro infiammatorio. Riportiamo qui di seguito il caso di un giovane uomo che si presentava alla nostra osservazione per un quadro clinico compatibile con la diagnosi di appendicite acuta; lo stesso è stato sottoposto ad appendicectomia laparoscopica, senza riscontro intraoperatorio di un quadro infiammatorio franco e l’analisi istologica successiva ha rivelato la presenza di un’enterobiasi da EV ad origine dal lume appendicolare.

To date, the exact pathophysiology of haemorrhoids is poorly understood. The different philosophies on haemorrhoids aetiology may lead to different approaches of treatment. A pathogenic theory involving a correlation between altered anal canal microflora, local inflammation, and muscular dyssynergia is proposed through an extensive review of the literature. Since the middle of the twentieth century, three main theories exist: (1) the varicose vein theory, (2) the vascular hyperplasia theory, and (3) the concept of a sliding anal lining. These phenomena determine changes in the connective tissue (linked to inflammation), including loss of organization, muscular hypertrophy, fragmentation of the anal subepithelial muscle and the elastin component, and vascular changes, including abnormal venous dilatation and vascular thrombosis. Recent studies have reported a possible involvement of gut microbiota in gut motility alteration. Furthermore, dysbiosis seems to represent the leading cause of bowel mucosa inflammation in any intestinal district. The alteration of the gut microbioma in the anorectal district could be responsible for haemorrhoids and other anorectal disorders. A deeper knowledge of the gut microbiota in anorectal disorders lays the basis for unveiling the roles of these various gut microbiota components in anorectal disorder pathogenesis and being conductive to instructing future therapeutics. The therapeutic strategy of antibiotics, prebiotics, probiotics, and fecal microbiota transplantation will benefit the effective application of precision microbiome manipulation in anorectal disorders.

Biomaterial-based-scaffolds’ functions are to replace anatomical and functional features loss of an injured tissue. They can replace native tissue after their reabsorption. Material and methods. In our experimental procedures we utilized the PHEA-PLA+PCL scaffold in 2 female pigs to assess its resistance to bile and urine. Results. Both pigs survived to surgical procedures. After a month fibres appeared unchanged in term of form and dimension at electronic microscopy. Cells and ECM factors were founded inside the scaffold in a microscopical evaluation. Conclusion. Planar and tubular scaffolds were colonized by cells and extracellular matrix elements. The study conducted on pig suggested that this type of material can resist to the action of bile and urine. This material could be proposed as a tissue substitute.

The role of augmented internal anal sphincter (IAS) tone in the genesis of chronic anal fissure (CAF) is still unclear. Lateral internal sphincterotomy (LIS) is the most employed surgical procedure, aiming to reduce the IAS tone leaving a permanent anatomical alteration and it is burdened by high risk post-operative anal incontinence (AI). The aim of this work was to evaluate if the pre-operative manometric alterations of CAFs with hypertonic IAS would normalize after sphincter preserving surgical procedure.We enrolled 108 consecutive patients affected by idiopathic and non-recurrent CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement and pharmacological sphincterotomy, matched with 54 healthy subject in a 1 to 2 ratio, and followed up for at least for 2 years. The goals were patient's complete healing, the evaluation of AI, recurrence rate and manometry parameters.All wounds healed within 40 days after surgery. We recorded 7 cases of recurrences healed with medical therapy. We recorded 3 "de novo" post-operative cases of AI all temporary and low grade. Pre-operative values of maximum resting pressure (MRP) and detection of ultraslow wave activity (USWA) were significantly higher than in the healthy control group, but both come back to be similar to those recorded in healthy subject after 24 months from the surgery.The high healing rate without post-operative "de novo" AI cases with the normalization of manometric parameters suggest that fissurectomy and anoplasty with V-Y cutaneous advancement flap and pharmacological sphincterotomy is an adequate procedure for the treatment of CAF with IAS hypertonia.Anal fissure, Anoplasty, Fissurectomy, Proctology, Sphincterotomy.Il ruolo dell’aumento del tono dello sfintere anale interno nella patogenesi delle ragadi anali croniche (CAF) è a tutt’oggi dibattuto. La sfinterotomia laterale è la procedura chirurgica più frequentemente impiegata sebbene sia associata ad un incidenza di incontinenza anale postoperatoria del 14%. L’obbiettivo del nostro studio è quello di valutare, oltre alla guarigione delle CAF, se le alterazioni manometriche pre-operatorie nei pazienti affetti da CAF con ipertono sfinterico, si normalizzassero dopo asportazione della ragade e anoplastica con lembo mucocutaneo di scorrimento a V-Y nei pazienti con CAF. Sono stati studiati 108 pazienti affetti da CAF con ipertono. I risultati dello studio mostrano una guarigione di tutte le ferite entro 40 giorni dall’intervento chirurgico; sono stati osservati 7 casi di recidiva trattati efficacemente con terapia medica e 3 casi di incontinenza anale post-operatoria “de novo”, tutti temporanei e di lieve entità. La maximum resting pressure e la presenza di ultraslow wave activity pre-operatorie , a 24 mesi dall’intervento chirurgico, sono simili a quelle dei soggetti sani. L’alto tasso di guarigione in assenza di incontinenza anale post-operatoria permanente, e la normalizzazione dei valori manometrici, suggeriscono che quest’approccio “sphincter preserving” risulta valido per il trattamento delle ragadi anali croniche con ipertono sfinterico.

Le cisti mesoteliali del legamento rotondo sono una rara causa di tumefazione inguinale nelle donne, la loro eziopatogenesi rimare poco chiara e i casi riportati in letteratura sono scarsi. Inoltre, quest’ultime sono raramente prese in considerazione nella diagnosi differenziale delle tumefazioni della regione inguinale nelle pazienti di sesso femminile, ragion per cui sono spesso identificate solo in corso di esplorazione chirurgica e correttamente diagnosticate solo dopo esame istopatologico. Una donna di 57 anni (BMI 37 kg / m2) si è presentato nel nostro dipartimento con una massa inguinale sinistra, con storia di 2 mesi, che causava disagio locale e peggioramento progressivo del dolore locale. È stata fatta una diagnosi preoperatoria dell’ernia femorale sintomatica sinistra e la paziente ha acconsentito al trattamento chirurgico. L’esplorazione chirurgica dei canali inguinale i e femorale ha rivelato un’ernia femorale associata a una chiara lesione cistica fluida di circa 2 cm derivante dal legamento rotondo. L’istopatologia ha dimostrato una cisti mesoteliale del legamento rotondo CONCLUSIONI: Le cisti mesoteliali del legamento rotondo dell’utero devono essere prese in considerazione nella diagnosi differenziale del gonfiore inguinale nelle pazienti di sesso femminile e sono necessari maggiori sforzi per raggiungere una diagnosi preoperatoria e prevenire un trattamento eccessivo. L’indicazione chirurgica per queste lesioni rimane legata alla presenza di sintomi invalidanti, data la natura benigna delle stesse, per cui, al fine di evitare un overtreatment, ci sembra utile sottolineare innanzitutto, come questa entità patologica debba essere presa in considerazione nel percorso diagnostico di una tumefazione inguinale in soggetti di sesso femminile e in secondo luogo, l’utilità dell’esame ecografico di routine in queste pazienti. BACKGROUND: Differential diagnosis of inguinal mass must include, especially in female patients, a wide variety of lesions among which our analysis will focus on mesothelial cyst of the round ligament of the uterus. A rare developmental lesion often misdiagnosed as hernias and accidentally detected during surgical exploration of the groin region. CASE REPORT: Of a left inguinal mass causing local discomfort and progressive worsening of local pain. A pre-operative diagnosis of left symptomatic femoral hernia was made and the patient consented to surgical treatment. The surgical exploration of the inguinal and femoral canals revealed a femoral hernia associated to a clear fluid cystic lesion of around 2 cm arising from the round ligament. Histopathology demonstrated a mesothelial cyst of the round ligament CONCLUSIONS: Mesothelial cysts of the round ligament of the uterus must be taken into consideration in the differential diagnosis of groin swelling in female patients and a greater effort is needed in order to reach a preoperative diagnosis and prevent an over treatment. Key words: Mesothelial cyst, Preoperative diagnosis, Uterus.

Background: The possible relationships between breast and thyroid diseases have been reported in the literature. The purpose of our study was to evaluate the occurrence of histologically verified thyroid pathologies in women who were diagnosed with breast cancer and, after mastectomy/quadrantectomy complemented by oncological treatment, were thyroidectomized based on their periodic thyroid evaluation. Patients and Methods: Our series consist of 31 women with a mean age of 62.9 ± 10.9 years (range, 45–81) treated for breast cancer (18 right-sided, 11 left-sided, and 2 bilateral), of whom 29 were thyroidectomized, since two women who developed Graves’ disease refused thyroidectomy. These 31 women belong to a cohort of 889 women who referred to the Breast Surgery Unit of our university hospital during the period January 2010 through December 2020. Results: The mean time interval between breast cancer and thyroid pathologies was 48.1 ± 23.4 months (range, 12–95). The final diagnosis at histopathology was infiltrating ductal breast carcinoma in 26 women (with 2/26 patients having bilateral carcinoma) and infiltrating lobular breast carcinoma in the other 5 women. Ten of the twenty-nine thyroidectomized women (34.5%) had a thyroid malignancy on histology: five papillary carcinomas, three papillary micro-carcinomas and two follicular carcinomas. Two of the five women with papillary carcinoma also had histological evidence of chronic lymphocytic thyroiditis/Hashimoto’s thyroiditis, which was also detected in another five women with benign thyroid diseases. Conclusions: We suggest that breast cancer survivors should be made aware of the possible increased risk of thyroid pathologies (including thyroid malignancy) so that they can undergo screening and follow-up.

INTRODUCTION: Lateral internal sphincterotomy (LIS) is still the approach of choice for the treatment of chronic anal fissure (CAF) regardless to the internal anal sphincter tone but it is burdened by high risk post-operative faecal incontinence (FI). In female patient there are some anatomical and functional differences of the sphinteric system which make them more at risk of FI and vaginal birth could cause sphinteric lesions affecting the anal continence function. The aim of our study is to evaluate the results of saving sphincter procedure as treatment for female patients affected by CAF. METHODS: We studied 110 female patients affected by CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement associating pharmacological sphincterotomy in patients with hypertonic IAS. The follow up was at least for 2 years. The goals were patient’s complete healing, the evaluation of FI, recurrence rate and manometry parameters. RESULTS: All wounds healed within 40 days after surgery. We recorded 8 cases of recurrences 6 healed with medical therapy and 2 with dilatation. We recorded 2 “de novo” temporary and low grade post-operative cases of FI. Post-operative value of MRP were unmodified in patient with normotonic IAS but significantly lower at 12 months follow up as compared with the pre-operative ones in patients with hypertonic IAS; after 24 months from surgery MRP values were within the normal range. CONCLUSION: The fissurectomy and anoplasty with V-Y cutaneous flap alone or in association with a pharmacological sphincterotomy in patients with hypertonic IAS may represent an effective approach for the treatment of CAF in female patients.

BACKGROUND Lateral internal sphincterotomy is still the approach of choice for the treatment of chronic anal fissure (CAF) with internal anal sphincter (IAS) hypertonia, but it is burdened by high-risk postoperative faecal incontinence (FI). Sphincter saving procedures have recently been reconsidered as treatments to overcome this risk. The most employed procedure is fissurectomy with anoplasty, eventually associated with pharmacological sphincterotomy. AIM To evaluate whether fissurectomy and anoplasty with botulinum toxin injection improves the results of fissurectomy and anoplasty alone. METHODS We conducted a case-control study involving 30 male patients affected by CAF with hypertonic IAS who underwent fissurectomy and anoplasty with V-Y cutaneous flap advancement. The patients were divided into two groups: Those in group I underwent surgery alone, and those in group II underwent surgery and a botulinum toxin injection directly into the IAS. They were followed up for at least 2 years. The goals were to achieve complete healing of the patient and to assess the FI and recurrence rate along with manometry parameters. RESULTS The intensity and duration of post-defecatory pain decreased significantly in both groups of patients starting with the first defecation, and this reduction was higher in group II. Forty days after surgery, we achieved complete wound healing in all the patients in group II but only in 80% of the patients in group I (P < 0.032). We recorded 2 cases of recurrence, one in each group, and both healed with conservative therapy. We recorded one temporary and low-grade postoperative case of “de novo” FI. Manometry parameters reverted to the normal range earlier for group II patients. CONCLUSION The injection of botulinum toxin A in association with fissurectomy and anoplasty with a V-Y advancement flap improves the results of surgery alone in patients affected by CAF with IAS hypertonia.

Purpose: Anal Fissure (AF) is the second most frequent proctological disease in Italy. Chronic AF (CAF) most common located at the posterior anal commissure (CAPF). CAPF are thought to be associated with hypertonic internal anal sphincter (IAS) but manometric findings showed that a normotonic IAS is present in the 20-40%. Sphincterotomy is often recommended as treatment of choice for CAF independently from IAS tone; nevertheless, this approach appears less logical for CAF with normotonic IAS, as in those cases there’s a higher risk of post-operative anal incontinence. The aim of this study is to evaluate the results of fissurectomy and anoplasty with V-Y cutaneous advancement flap, as treatment for patients suffering from CAPF without hypertonic IAS. Methods: We enrolled 30 patients affected by CAPF without IAS hypertonia. All patients were followed up for 2 years after the surgical procedure, with evaluation of anal continence, recurrence rate and maximum resting pressure, maximum squeeze pressure, ultraslow wave activity. Results: All patients healed within 40 days after surgery. We didn’t observe any “de novo” post-operative anal incontinence cases. We reported 2 cases of recurrences, within 18 months from surgery, all healed after con-servative therapy. We didn’t record statistically significant differences in pre-and post-operative manometry findings. Conclusion: At 2 years after the surgical procedure we achieved good results, these evidences shows that sphincter preserving procedures are more suitable for CAPF without hypertonic IAS.

Aetiopathogenesis of Chronic Anal Anterior Fissure (CAAF) remains poorly understood. Some anatomical, clinical and functional features suggest that pathophysiology may be linked to a reduced anal canal pressure. LIS appear illogical as a treatment for CAAF and the employ of techniques aiming to save the integrity of the sphincterial system appears more sensible. The aim of this study was to evaluate 5 years results of fissurectomy and anoplasty with cutaneous V-Y advancement flap in patients affected by CAAF without IAS hypertonia.We enrolled 20 women, affected by idiopathic and non-recurrent CAAF without hypertonic IAS. All patients were followed up for 5 years after surgery with evaluation of anal continence, short and long term post-operative complications, recurrence rate.At 5 years follow up we did not record any new case of anal incontinence and the pre-existing ones haven't worsened. We observed 2 recurrences, which occurred within 2 years after surgery and healed after medical therapy. The manometric values were similar than those recorded prior to surgery.Our study suggests that the procedure performed allows us to preserve anal continence and avoid worsening of its pre-existing alteration.Anal canal, Anoplasty, Fissure, Fissurectomy, Proctology, Sphincterotomy.L’eziopatogenesi delle ragadi anali della commisura anteriore è ancora poco chiara. Alcune caratteristiche cliniche, anatomiche e funzionali suggerirebbero che la patofisiologia di questo disturbo sia strettamente correlata alla riduzione del tono sfinterico anale. La sfinterotomia laterale interna è un approccio poco appropriato per questa patologia, mentre, le procedure volte a garantire l’integrità del sistema sfinterico sembrerebbero più ragionevoli. L’obbiettivo del nostro studio è quello di valutare i risultati a 5 anni della fissurectomia ed anoplastica con lembo di avanzamento cutaneo a V-Y per il trattamento delle ragadi anali della commissura anteriore senza ipertono sfinterico. Al fine di condurre il nostro studio abbiamo considerato 20 pazienti donne affette da ragade anale e sottoposte al suddetto intervento chirurgico dal Gennaio 2008 al Gennaio 2015; tutte le pazienti sono state seguite per 5 anni dopo la procedura chirurgica con valutazione della continenza anale, delle complicanze post-operatorie e breve e lungo termine e del tasso di ricorrenza. Al follow up a 5 anni non abbiamo riscontrato nessun caso di incontinenza anale di nuova insorgenza, è alcun aggravamento dei casi di incontinenza anale preesistenti. Abbiamo osservato 2 recidive trattate efficacemente con terapia conservativa. Infine, il quadro manometrico a 5 anni era simile a quello pre-operatorio. In conclusione il nostro studio suggerisce che la procedura chirurgica da noi utilizzata ci permette di conservare la continenza anale in queste pazienti, senza aggravare le preesistenti alterazioni della stessa.

INTRODUZIONE: La SMVT è una seria, rara complicanza della chirurgia addominale. I fattori di rischio sono molteplici, ma scarsamente descritti tanto che i dati sono insufficienti per creare gold standard per la diagnosi e trattamento. La SMVT ha un ampio spettro di presentazioni cliniche, così che spesso la sua diagnosi precoce può essere complessa. CASE REPORT: Una donna obesa di 56 anni con un disordine protrombotico ereditario è stata sottoposta ad emicolectomia destra e colecistectomia open; l’immediato decorso post-operatorio è stato regolare e la paziente è stata dimessa in quinta giornata post-operatoria. In ottava giornata post-operatoria la paziente ha presentato dolore addominale diffuso post-prandiale, in assenza di altri segni o sintomi. La CT ha mostrato una trombosi completa della vena mesenterica superiore senza sofferenza intestinale. La paziente è stata quindi immediatamente sottoposta a terapia sistemica anticoagulante sottocutanea convertita successivamente ad anticoagulanti orali sine die, con completa risoluzione clinica in diciassettesima giornata post-operatoria, nonostante la persistenza radiologica della completa trombosi della vena mesenterica superiore in assenza di segni di sofferenza colica. DISCUSSIONE: La trombosi della vena mesenterica superiore è una condizione ad eziologica multifattoriale. Attualmente mancano dati conclusivi riguardo il confronto della sua incidenza nella chirurgia open o laparoscopica e, in gruppi di pazienti oncologici e non in relazione alla tecnica chirurgica. La diagnosi è resa difficoltosa dalla variabilità di presentazione clinica e dall’assenza di sintomi, segni e alterazioni di laboratorio specifiche, così che per la diagnosi, è necessario avere un alto indice di sospetto. Per quanto riguarda la terapia, l’approccio di prima linea prevede una terapia anticoagulante sistemica con EBPM per almeno 6 mesi con un successivo passaggio alla terapia anticoagulante orale; prima si inizia la terapia più alto sarà il tasso di rivascolarizzazione. CONCLUSIONI: Una diagnosi precoce e una più aggressiva profilassi antitrombotica in pazienti con fattori di rischio congeniti o acquisiti possono prevenire una evoluzione negativa della SMVT. AIM: Superior mesenteric vein thrombosis (SMVT) is an uncommon but potentially life-threatening postoperative complication of colorectal surgery. Risk factors and prognosis of SMVT have been poorly described and data to create gold standard criteria for diagnosis and management are lacking. SMVT has a wide spectrum of clinical presentation, hence, its early identification may be a diagnostic challenge. CASE REPORT: 56 year old obese female patient with inherited prothrombotic condition underwent an open right hemicolectomy plus cholecystectomy; the immediate postoperative course was uneventful but on postoperative day 8, already at home, she experienced post-prandial abdominal pain without any other local or systemic signs or symptoms. The CT scan showed a complete thrombosis of the superior mesenteric vein without any bowel complications. Immediately submitted to systemic subcutaneous anticoagulation bridge therapy to a lifelong oral anticoagulation she had a complete clinical recovery on postoperative day 17, despite the persistence at CT scan of complete SMVT without any intestinal suffering. DISCUSSION: SMVT is a multifactorial event where both local and general factors are involved. Conclusive data about comparison of SMVT incidence in laparoscopic vs open colorectal surgery and those about its incidence in cancer vs non cancer groups of patients in relation to the surgical technique are missing. Variability of clinical course and the absence of specific signs, symptoms and laboratory findings make diagnosis of SMVT challenging, therefore it is crucial to have high suspicion. As for the treatment, first line approach is systemic anticoagulation therapy with LMWH for at least 6 months, followed by oral anticoagulation, the earlier we initiate the therapy the greater rate of recanalization we will get. CONCLUSION: prompt diagnosis and more aggressive thromboprophylaxis in patients with inherited or acquired risk factors may prevent the negative evolution towards bowel necrosis of SMVT. KEY WORDS: Colorectal surgery, Superior mesenteric vein thrombosis, Hypercoagulable disorders, Thromboprophylaxis.

Surgical site infections (SSI) are a common cause of health care-associated infections. They are localized in the surgical incision site and can lead to deep tissues spreading. Among the wide spectrum of SSIs , we will consider specifically group A streptococcus cellulitis. This kind of infection can have a negative evolution and result in necrotizing fasciitis (NF), previously known as streptococcal gangrene. The term NF indicates a rare necrotizing infection involving any of the soft tissue layers that still have a high mortality rate from 7% to 76%. An early diagnosis and urgent treatment are key to ensuring the safety of the patients’ life. A 64-year-old man underwent a complete surgical removal of an inguinal lipoma. A few hours after the procedure, he developed initial signs of streptococcal cellulitis. Thanks to an early diagnosis, a multidisciplinary management was established and after 20 days the patient was discharged from our department in good, general clinical conditions. Our experience has shown how good clinical control and the early evaluation of any clinical warning signs beginning in the very first few hours after the surgical procedure are important in order to prevent clinical and local conditions from worsening. Moreover, we underline the great utility of a combined management led by a multidisciplinary team based on antimicrobial therapy, hyperbaric oxygen therapy and surgical approach that could be the key to ensure safety of the patients’ life.

Patients undergoing surgery for recurrent pilonidal disease are at high risk of developing re-recurrence. The present prospective analysis was performed to evaluate the outcome for recurrent pilonidal disease treatment with a technique that provides a minimal subcutaneous excision of fistula and of the skin above the cyst, with secondary healing of wounds.48 consecutive patients with previous surgical excision and recurrent pilonidal disease underwent surgery from January 2009 to December 2016, under local anaesthesia. The age of the patients (42 males and 6 females) at the time of our observation was 28.5 ± 10.2 years, the BMI of 26.3 ± 6.8. The average number of interventions prior to our was 2.02 ± 1.14.The mean operative time was 18.2 ± 5.5 minutes. All patients were discharged 2 to 4 hours after surgery, with an average healing time of 22.8 ± 15.3 days. We recorded, in the follow-up period, only 4 relapses (8.32%), all retreated with the same surgical procedure and brought to complete healing. The results of the cosmetic questionnaire, which assessed patient satisfaction and contentment, showed that 96% of patients were completely satisfied and all patients recommended surgery to others. Kaplan-Meier analysis showed that in 7 years of follow-up, 85% of patients healed without recurrence.Our simple procedure appears to be safe and easily reproducible, allowing a high surgical success in the treatment of recurrent pilonidal disease.Excision, Healing, Recurrent sacrococcygeal pilonidal disease.I pazienti sottoposti a intervento chirurgico per malattia pilonidale sono ad alto rischio di sviluppare una recidiva. La nostra analisi prospettica è stata eseguita per valutare l’esito del trattamento della malattia pilonidale recidiva, mediante escissione sottocutanea minima del tramite fistoloso e della cute sopra la cisti, con Recurrent pilonidal disease guarigione per seconda intenzione. 48 pazienti consecutivi con precedente asportazione chirurgica di malattia pilonidale e attuale recidiva, sono stati sottoposti a chirurgia da gennaio 2009 a dicembre 2016, in anestesia locale. L’età dei pazienti (42 maschi e 6 femmine) al momento della nostra osservazione era di 28.5 ± 10.2 anni, il BMI di 26.3 ± 6.8. Il numero medio di interventi precedenti al nostro era di 2.02 ± 1.14. RISULTATI: Il tempo medio operatorio è stato di 18.2 ± 5.5 minuti. Tutti i pazienti sono stati dimessi da 2 a 4 ore dopo l’intervento chirurgico, con un tempo medi di guarigione di 22.8 ± 15.3 giorni. Abbiamo registrato, nel periodo di follow up, solo 4 recidive (8.32%), tutte ritrattate con la medesima procedura operatoria e portate a guarigione completa. I risultati del questionario cosmetico, che ha valutato la soddisfazione e la contentezza del paziente, hanno mostrato che il 96% dei pazienti era completamente soddisfatto e tutti i pazienti raccomandavano l’intervento chirurgico ad altri. L’analisi di Kaplan-Meier ha dimostrato che in 7 anni di follow-up l’85% dei pazienti è andato incontro a guarigione in assenza di recidiva. CONCLUSIONI: La nostra semplice procedura appare sicura e facilmente riproducibile, consentendo un elevato successo chirurgico nel trattamento della malattia pilonidale recidiva.

Colonoscopy is a routine procedure performed worldwide, nevertheless, a small risk of splenic injury, often under-estimated, is still present. As a matter of fact, the diagnosis may be delayed, leading to a rising risk of morbidity and mortality. This paper describes a case of conservative treatment of colonoscopy-associated splenic injury. A 57-year-old woman presented with worsening pain in the upper left abdominal quadrant; she had radiation therapy to the ipsilateral subscapular region, and a diagnostic colonoscopy 18 hours earlier. The computed tomography (CT) scan revealed splenic laceration without signs of hemoperitoneum. Because of the hemodynamic stability of the patient, successfulconservative treatment and serial controls of the blood and hemodynamic parameters were adopted. Even if rare splenic injury during colonoscopy is associated with significant morbidity and mortality. A high degree of clinical suspicion is essential to achieve a prompt diagnosis as well as an early surgical evaluation. The nonoperative approach is usually taken in patients with no intraperitoneal bleeding, a closed subcapsular haematoma and a stable hemodynamic status.

In recent years, a new gluten- or wheat-related disease has emerged, a condition labeled "nonceliac gluten sensitivity" (NCGS) or "nonceliac wheat sensitivity" (NCWS). NCWS pathogenesis is still uncertain and attributed to very different mechanisms. We aimed to study the different T-lymphocyte subsets in the rectal mucosa of NCWS patients to demonstrate the possible contribution of adaptative immune response. Twelve patients (11 women, 1 man, age range 23-61 yr, median 32 yr) with a definitive diagnosis of NCWS were recruited at random for the present study. They underwent rectal endoscopy with multiple mucosal biopsies at the end of a double-blind placebo-controlled (DBPC) wheat challenge when they reported the reappearance of the symptoms. As controls we included 11 "healthy patients", sex- and age-matched with the patients who underwent colonoscopy evaluation for rectal bleeding due to hemorrhoids. Cells freshly obtained from rectal tissue were stained to detect anti-CD45, anti-CD3, anti-CD4, and anti-CD8. Furthermore, intracellular staining was performed with anti-tumor necrosis factor (TNF)-α, anti-interleukin (IL)-17, and anti-IL-22. Production of TNF-α by CD45+, CD3+, CD4+, and CD8+ cells, as well as of IL-17 by CD4+ cells, was higher in the rectal tissue of NCWS patients than in controls. On the contrary, IL-22 production by CD8+ cells was lower in NCWS patients than in the controls. In NCWS patients diagnosed by DBPC wheat challenge, there is a complex immunological activation, with a significant role for the adaptive response.NEW & NOTEWORTHY Nonceliac wheat sensitivity (NCWS) is a syndrome characterized by symptoms triggered by gluten intake. The pathogenesis is still uncertain. Studies have shown a role for innate immunity. We demonstrated that production of TNF-α by CD45+, CD3+, CD4+, and CD8+ cells and of IL-17 by CD4+ cells is higher in the rectal tissue of NCWS patients than in controls. We clearly demonstrated that in patients with NCWS there is a significant role for the adaptive response.

Chronic anal fissure’s (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V–Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V–Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 “de novo” post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up post-operative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF.

INTRODUCTION: Nonceliac wheat sensitivity (NCWS) is characterized by intestinal and extraintestinal manifestations consequent to wheat ingestion in subjects without celiac disease and wheat allergy. Few studies investigated the relationship between NCWS and autoimmunity. The aim of this study is to evaluate the frequency of autoimmune diseases (ADs) and autoantibodies in patients with NCWS. METHODS: Ninety-one patients (13 men and 78 women; mean age of 40.9 years) with NCWS, recruited in a single center, were included. Seventy-six healthy blood donors (HBD) and 55 patients with a diagnosis of irritable bowel syndrome (IBS) unrelated to NCWS served as controls. Autoantibodies levels were measured. Human leukocyte antigen haplotypes were determined, and duodenal histology performed in all patients carrying the DQ2/DQ8 haplotypes. Participants completed a questionnaire, and their medical records were reviewed to identify those with ADs. RESULTS: Twenty-three patients with NCWS (25.3%) presented with ADs; autoimmune thyroiditis (16 patients, 17.6%) was the most frequent. The frequency of ADs was higher in patients with NCWS than in HBD (P 5 0.002) and in patients with IBS (P 5 0.05). In the NCWS group, antinuclear antibodies tested positive in 71.4%vsHBD19.7%, and vs patients with IBS 21.8% (P < 0.0001 for both). The frequency of extractable nuclear antigen antibody (ENA) positivity was significantly higher in patients with NCWS (21.9%) than in HBD (0%) and patients with IBS (3.6%) (P 5 0.0001 and P 5 0.004, respectively). Among the patients with NCWS, 9.9% tested positive for antithyroglobulin, 16.5% for antithyroid peroxidase, and 14.3% for antiparietal cell antibodies; frequencies were not statistically different from controls. The presence of ADs was related to older age at NCWS diagnosis, female sex, duodenal lymphocytosis, and eosinophil infiltration. DISCUSSION: One in 4 patients withNCWS suffered from AD, and serum antinuclear antibodies were positive in a very high percentage of cases. These data led us to consider NCWS to be associated to ADs.

PURPOSE The role of augmented internal anal sphincter (IAS) tone in the genesis of posterior chronic anal fissure (CAPF) is still unknown. Lateral internal sphincterotomy is the most employed surgical procedure, nevertheless it is burdened by high risk post-operative anal incontinence. The aim of our study is to evaluate results of sphincter saving procedure with post-operative pharmacological sphincterotomy for patients affected by CAPF with IAS hypertonia. Methods: We enrolled 30 patients, undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement; all patients received topical administration of nifedipine 0.3% and lidocaine 1.5% ointment-based therapy before and for 15 days after surgery. The primary goal was patient's complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of manometry parameters, symptom relief and complications related to nifedipine and lidocaine administration. Results: All wounds healed within 40 days after surgery. We didn't observe any de novo postoperative anal incontinence case. We reported 2 cases of recurrences, healed after conservative therapy. We didn't report any local complications related to the administration of the ointment therapy; with whom all patients reported a good compliance. Conclusions: Fissurectomy and anoplasty with V-Y cutaneous advancement flap and topical administration of nifedipine and lidocaine, is an effective treatment for CAPF with IAS hypertonia.

Agenesis of the gallbladder is an extremely rare congenital entity with shaded clinical and radiologic features, which make the preoperative diagnosis really challenging. Here, we report a case of a 52-year-old symptomatic female with biliary symptoms and contracted gallbladder at ultrasound (US). The final diagnosis was made with magnetic resonance cholangiopancreatography (MRCP) and the treatment was conservative. However, diagnosing this condition preoperatively is still challenging. However, with innovations in terms of biliary tract imaging technique, and with better knowledge of this entity, many unnecessary surgical procedures might be avoided.

Umbilical hernia is a very frequent pathology, and plastic with prosthetic material is the most frequently used surgical procedure currently used for its repair. In patients with cirrhosis in asciic phase, this pathology is particularly frequent, with a tendency to rapidly increase in size and to become symptomatic. In the past treatment with traditional surgery in cirrhotic patients was considered problematic and was viewed with reserve, and only recently is the surgical approach recommended also in these patients. This study is aimed to evaluate the feasibility and safety of open umbilical hernia plastic with prosthetic material in cirrhotic and ascitic patients.Our case-control study was conducted on 35 male patients with ascitic phase liver cirrhosis and an equal number of non-cirrhotic patients, all suffering from uncomplicated but symptomatic umbilical hernia, treated surgically consecutively from March 2005 to March 2015. All patients underwent open umbilical hernioplasty with placement of a retromuscular pre-aponeurotic mesh.Of the 35 patients with liver cirrhosis, 20% were classified in Class C, according to Child-Pugh, 28.5% had a MELD score15. We have not shown any post-operative mortality. In general, minor complications were observed, more frequent in cirrhotic patients than in healthy controls (p = 0.0315). Among the aforementioned complications the most frequent were hematomas and wound infections, more frequent in cirrhotic patients in Class C according to Child- Pugh and with MELD score15 (p0.005).Our study shows that umbilical hernia pathology in ascitic cirrhotic patients can be treated surgically with satisfactory results especially in Child-Pugh class A and B patients. The surgical approach of choice must, preferably, be the preferred prosthetic plastic after pre-operative optimization of the coagulation, nutritional and ascitic state.Ascites, Hernioplasty ,Liver cirrhosis; Umbilical hernia.L’ernia ombelicale è una patologia molto frequente, e la plastica con materiale protesico è la procedura chirurgica di più frequente uso attualmente per la sua riparazione. Nei pazienti affetti da cirrosi in fase ascitica, questa patologia è particolarmente frequente, con una tendenza ad aumentare rapidamente di dimensioni e a divenire sintomatica. Nel passato il trattamento con chirurgia tradizionale nei pazienti cirrotici era considerato problematico ed era visto con riserva, e solo recentemente si raccomanda l’approccio chirurgico anche in questi pazienti. Questo studio intende a valutare la fattibilità e la sicurezza della plastica dell’ernia ombelicale con materiale protesico open in pazienti cirrotici in fase ascitica.Il nostro studio caso-controllo è stato condotto su 35 pazienti di sesso maschile affetti da cirrosi epatica in fase ascitica e un egual numero di pazienti non cirrotici, tutti affetti da ernia ombelicale non complicata ma sintomatica, trattati chirurgicamente consecutivamente dal Marzo 2005 al Marzo 2015. Tutti i pazienti sono stati sottoposti ad ernioplastica ombelicale open con posizionamento di una mesh retromuscolare prefasciale.Dei 35 pazienti affetti da cirrosi epatica, il 20% è stato classificato in Classe C, secondo Child-Pugh, il 28,5% aveva un MELD score15. Non abbiamo evidenziato alcuna mortalità post-operatoria. In generale, sono state osservate complicanze di lieve entità, più frequenti nei pazienti cirrotici rispetti ai controlli sani (p=0,0315). Tra le suddette complicanze le più frequenti sono state ematomi ed infezioni della ferita, più frequenti in pazienti cirrotici in Classe C secondo Child-Pugh e con MELD score15 (p0,005). CONCLUSIONI: il nostro studio mostra che la patologia erniaria ombelicale nei pazienti cirrotici in fase ascitica può essere trattata chirurgicamente con risultati soddisfacenti soprattutto in pazienti in classe A e B di Child- Pugh. L’approccio chirurgico di scelta deve essere, preferibilmente, la plastica protesica di elezione previa ottimizzazione pre-operatoria dello stato coagulativo, nutrizionale e ascitico.

Background: laparoscopic adrenalectomy has become the standard treatment for adrenal lesions. The better clinical outcoms of laparoscopic technique are valid for treatment of small benign masses (< 5-6 cm), instead there are still open questions in literature regarding the correct management of larger lesions (> 6 cm) or in case of potentially malignant adrenal tumors. The aim of this study is to evaluate the outcomes of laparoscopic adrenalectomy in a referral surgical department for endocrine surgery. Methods: at the University Hospital Policlinico "P. Giaccone" of Palermo between January 2010 and December 2017 we performed a total of 81 laparoscopic adrenalectomy. We created a retrospective database with analysis of patients data, morphologic and hormonal characteristics of adrenal lesions, surgical procedures and postoperative results with histological diagnosis and complications. Results: Mean size of adrenal neoplasm was 7,5 cm (range 1.5 to 18 cm). The mean operative time was 145 min (range 75-240). In statistical analysis lenght of surgery was correlated to the lesion diameter (p < 0.05) but not with pre-operative features or histological results. 5 intraoperative complications occurred. Among these patients 4 presented bleeding and 1 a diaphagmatic lesion. No conversion to open surgery was necessary and no intraoperative blood transfusion were required. Mean estimated blood loss was 95 ml (range 50-350). There was no capsular disruption during adrenal dissection. Mean length of hospital stay was 3.7 days (range 3-6 days). Conclusions: Laparoscopic adrenalectomy is a safe procedure with low rate of morbidity. An accurate preoperative radiological examination is fundamental to obtain a stringent patients selection. The lesion diameter is related to longer operative time and appeares as the main predictive parameter of intraoperative complications but these results are not statistically significant. On the other side secreting adrenal tumors require more attention in operative management without increased rate of postoperative complications.

Background: Development of seroma after incisional hernia repair is a common complication. Our study aims to compare the outcomes of sublay incisional hernia repairs with or without spray instillation of fibrin glue. Methods: We enrolled fifty patients undergoing incisional hernia repair. In all patients a suction drain was placed in the subcutaneous space. In one group (FG) 4 ml fibrin glue was instilled in the subcutaneous space. In the control group (C) patients did not receive any prevention measure. Wounds fluids were collected on post-operative day 1 (POD) and once daily until drain removal. All patients were followed up by ultrasound on POD 15, 20, 40, 60. Results: Drain fluid production, even if in significantly greater amount in the C group (p 0.01) as compared with the FG group, decreased after POD 1 in both groups. Drain was removed on POD-5 in 80% of FG patients and in 36% of C patients (p 0.01). No infective or bleeding complications were detected. In group FG average hospital stay was of 5.5 ÃÂ+- 2 days versus 7.1 +- 1.5 days in group C (p 0.01). At ultrasounds examination, seroma development was similar among two groups. Conclusions: Spray instillation of fibrin glue during the surgical repair reduces amount of drained fluid and hospital stay without increasing surgical complications. However, seroma occurrence was not significantly reduced.

Background The incidence rate of abdominal wall hernia is 20–40% in cirrhotic patients. A surgical approach was originally performed only if complication signs and symptoms occurred. Several recent studies have demonstrated the usefulness of elective surgery. During recent decades, the indications for surgical timing have changed. Methods Cirrhotic patients with abdominal hernia who underwent surgical operation for abdominal wall hernia repair at the Policlinico “Paolo Giaccone” at Palermo University Hospital between January 2010 and September 2016 were identified in a prospective database, and the data collected were retrospectively reviewed; patients’ medical and surgical records were collected from charts and surgical and intensive care unit (ICU) registries. Postoperative morbidity was determined through the Clavien-Dindo classification. Cirrhosis severity was estimated by the Child-Pugh-Turcotte (CPT) score and MELD (model of end-stage liver disease) score. Postoperative mortality was considered up to 30 days after surgery. A follow-up period of at least 1 year was used to evaluate hernia recurrence. Results The univariate and multivariate analyses demonstrated the unique independent risk factors for the development of postsurgical morbidity (emergency surgery (OR 6.42; p 0.023), CPT class C (OR 3.72; p 0.041), American Society of Anesthesiologists (ASA) score ≥ 3 (OR 4.72; p 0.012) and MELD ≥ 20 (OR 5.64; p 0.009)) and postsurgical mortality (emergency surgery (OR 10.32; p 0.021), CPT class C (OR 5.52; p 0.014), ASA score ≥ 3 (OR 8.65; p 0.018), MELD ≥ 20 (OR 2.15; p 0.02)). Conclusions Concerning abdominal wall hernia repair in cirrhotic patients, the worst outcome is associated with emergency surgery and with uncontrolled disease. The correct timing of the surgical operation is elective surgery after ascites drainage and albumin/electrolyte serum level and coagulation alteration correction.

BACKGROUND: Heat shock protein 60 (Hsp60) is a chaperonin involved in tumorigenesis, but its participation in tumor development and progression is not well understood and its value as a tumor biomarker has not been fully elucidated. In the current study, the authors presented evidence supporting the theory that Hsp60 has potential as a biomarker as well as a therapeutic target in patients with large bowel cancer. METHODS: The authors studied a population of 97 subjects, including patients and controls. Immunomorphology, Western blot analysis, and quantitative real-time polymerase chain reaction were performed on tissue specimens. Exosomes were isolated from blood and characterized by electron microscopy, biochemical tests, and Western blot analysis. RESULTS: Hsp60 was found to be increased in cancerous tissue, in which it was localized in the tumor cell plasma membrane, and in the interstitium associated with cells of the immune system, in which it was associated with exosomes liberated by tumor cells and, as such, circulated in the blood. An interesting finding was that these parameters returned to normal shortly after tumor removal. CONCLUSIONS: The data from the current study suggested that Hsp60 is a good candidate for theranostics applied to patients with large bowel carcinoma and encourage similar research among patients with other tumors in which Hsp60 has been implicated. Cancer 2015;000:000–000. V C 2015 American Cancer Society.

Highlights • Stump appendicitis (SA) is a rare, but noteworthy, diagnosis that warrants early detection. • Delay in the diagnosis of SA may result in serious complications like stump gangrene, perforation and peritonitis. • More research is needed to identify strategies to prevent SA. • We underline the emergent role of lower endoscopy to clarify diagnosis resolve the symptoms. • Surgeons need to have a heightened awareness of the possibility of SA., Introduction Today, the diagnosis of SA is usually not considered as the etiology for right lower quadrant pain in patient with history of appendectomy, resulting in delaying making the correct diagnosis and treatment. Obviously, other more common causes should be excluded first. Discussion Stump appendicitis (SA) was first described by Rose in 1945. The commonest presenting symptom are abdominal pain (right lower quadrant pain 59%, non specific abdominal pain 16%, and central abdominal pain radiating to the right lower quadrant 14%). Presentation of case A 54-year-old appendectomized woman presented with recent history of abdominal pain with periumbilical pain radiating to the right side and in the right iliac fossa, in the absence of fever, vomiting or other symptoms. Elective colonoscopy revealed appendicular orifice clogged by big fecalith, with hyperemic surrounding mucosa and CT confirmed “stump appendicitis”. After 30 days of therapy with metronidazole 500 mg/day and mesalazine 1000 mg × 2/day, the patient was submitted to surgery and appendectomy was performed, with a specimen of 24 mm stump appendicitis. Conclusion SA may well be considered as one of the differential diagnoses of acute right lower abdominal pain even in patients with history of appendicectomy.

Patients with thoracic trauma constitute one third of all the trauma cases, in west Sicily were recorded 941 thoracic trauma during the period between 2006 and 2009. Sicily is one of the Italian regions with the highest rate of obesity: some studies have demonstrated that obesity is an independent risk factor for mortality in high energy blunt traumas.This study was conducted with trauma patients older than 20 years old who presented to our Department during the last five years. We only included thoracic injuries and politrauma with a thoracic involvement and a BMI25. Patients were divided into two groups: HET and LET patients.Thoracic trauma was more common in patients with a BMI25 than in normo-weight and clinic admission rate, length of hospital stay and ISS score increased in proportion with the increase of BMI. Both HET (high energy trauma) and LET (low energy trauma) revealed that overweight, obese and morbidly obese patients had greater admissions and length of hospital stay.The overweight and obese population has increased substantially over the last two decades and 61,5% of the Sicilian population is above normal weight. A large body mass with excess adiposity may contribute to HET injuries in several ways. Obesity has a number of comorbidities that reduce chances of recovery in overweight and obese patients experienced thoracic trauma both HET and LET.Obesity increases morbidity independently of injury severity in thoracic trauma patients. As BMI increased, length of hospital stay increased and prognosis deteriorates.BMI, Obesity, Thoracic trauma.Circa un terzo di tutti I casi di trauma è rappresentato da trauma del torace. Nella Sicilia occidentale, tra il 2006 e il 2009, sono stati riportati 941 casi di trauma del torace. La Sicilia è una delle regioni italiane con il tasso di obesità maggiore: alcuni studi hanno dimostrato come l’obesità rappresenti un fattore di rischio per mortalità nei traumi contusivi ad alta energia.Questo studio è stato condotto su pazienti traumatizzati, di età superiore a 20 anni, afferiti al nostro Dipartimento negli ultimi cinque anni. Nel campione abbiamo selezionato solo I trauma del torace e I politraumi con interessamento toracico e pazienti con BMI25. I pazienti sono stati suddivisi in due gruppi: HET e LET.I trauma del torace sono più comuni in pazienti con BMI25 che nei normo-peso. Tasso di ammissione ospedaliera, durata della degenza e indice ISS aumentano all’aumentare del BMI sia negli HET che nei LET.La popolazione sovrappeso e obesa è aumentata nelle ultime due decadi; il 61,5% dei siciliani sono sovrappeso. Una massa corporea con eccesso di adipe sembra contribuire alla morbilità nei traumi ad alta energia. L’obesità si accompagna a comorbidità che riducono le possibilità di recupero nei pazienti sovrappeso e obesi con un trauma toracico ad alta e a bassa energia.L’obesità aumenta la morbilità indipendentemente dalla gravità delle lesioni nei pazienti con trauma toracico. All’aumentare del BMI, si allunga la durata della degenza ospedaliera e la prognosi peggiora.

We investigated how many patients with a diagnosis of nonceliac wheat sensitivity (NCWS) still experienced wheat sensitivity after a median follow-up time of 99 months. We collected data from 200 participants from a previous study of NCWS, performed between July and December 2016 in Italy; 148 of these individuals were still on a strict wheat- free diet. In total, 175 patients (88%) improved (had fewer symptoms) after a diagnosis of NCWS; 145 of 148 patients who adhered strictly to a gluten-free diet (98%) had reduced symptoms, compared with 30 of 52 patients who did not adhere to a gluten-free diet (58%) (P < .0001). Of the 22 patients who repeated the double-blind, placebo- controlled challenge, 20 reacted to wheat. We conclude that NCWS is a persistent condition. Clinicaltrials.gov registration number: NCT02823522.

Background: Non‐celiac wheat sensitivity (NCWS) is a new clinical entity in the world of gluten‐related diseases. Nickel, the most frequent cause of contact allergy, can be found in wheat and results in systemic nickel allergy syndrome and mimics irritable bowel syndrome (IBS). Objective: To evaluate the frequency of contact dermatitis due to nickel allergy in NCWS patients diagnosed by a double‐blind placebo‐controlled(DBPC)challenge,and to identify the characteristics of NCWS patients with nickel allergy. Methods: We performed a prospective study of 60 patients (54 females, 6 males; mean age 34.1 ± 8.1 years) diagnosed with NCWS from December 2014 to November 2016; 80 age‐ and sex‐matched subjects with functional gastrointestina l symptoms served as controls. Patients reporting contact dermatitis related to nickel‐containing objects underwent nickel patch test (Clinicaltrials.gov registration number: NCT02750735).Results: Six out of sixty patients (10%) with NCWS suffered from contact dermatitis and nickel allergy and this frequency was statistically higher (p = 0.04)than observed in the control group(5%. The main clinical characteristic of NCWS patients with nickel allergy was a higher frequency of cutaneous symptoms after wheat ingestion compared to NCWS patients who did not suffer from nickel allergy (p < 0.0001. Conclusions: Contact dermatitis and nickel allergy are more frequent in NCWS patients than in subjects with functional gastrointestinal disorders;furthermore, these patients had a very high frequency of cutaneous manifestations after wheat ingestion. Nickel allergy should be evaluated in NCWS patients who have cutaneous manifestations after wheat ingestion.

Background & Aims: Studies of non-celiac gluten or wheat sensitivity (NCGWS) have increased but there are no biomarkers of this disorder. We aimed to evaluate histologic features of colon and rectal tissues from patients with NCGWS. Methods: We performed a prospective study of 78 patients (66 female; mean age, 36.4 years) diagnosed with NCGWS by double-blind wheat challenge at 2 tertiary care centers in Italy, from January 2015 through September 2016. Data were also collected from 55 patients wither either celiac disease or self-reported NCGWS but negative results from the wheat-challenge test (non-NCGWS controls). Duodenal and rectal biopsies were collected and analyzed by immunohistochemistry to quantify intra-epithelial CD3 + T cells, lamina propria CD45 + cells, CD4 + and CD8 + T cells, mast cells, and eosinophils and to determine the presence and size of lymphoid nodules in patients with NCGWS vs patients with celiac disease or non-NCGWS controls. Results: Duodenal tissues from patients with NCGWS had significantly higher numbers of intra-epithelial CD3 + T cells, lamina propria CD45 + cells, and eosinophils than duodenal tissues from non-NCGWS controls. Duodenal tissues from patients with NCGWS and dyspepsia had a higher number of lamina propria eosinophils than patients with NCGWS without upper digestive tract symptoms. Rectal mucosa from patients with NCGWS had a larger number of enlarged lymphoid follicles, intra-epithelial CD3 + T cells, lamina propria CD45 + cells, and eosinophils than rectal mucosa from non-NCGWS controls. Duodenal and rectal mucosal tissues from patients with celiac disease had more immunocytes (CD45 + cells, CD3 + cells, and eosinophils) than tissues from patients with NCGWS or non-NCGWS controls. Conclusions: We identified markers of inflammation, including increased numbers of eosinophils, in duodenal and rectal mucosa from patients with NCGWS. NCGWS might therefore involve inflammation of the entire intestinal tract. Eosinophils could serve as a biomarker for NCGWS and be involved in its pathogenesis. Clinicaltrials.gov: NCT01762579.