Purpose: The aim of this work is to characterize the shape and the volume of the internal anal sphincter (IAS) in normal subjects by three-dimensional anorectal ultrasonography. Methods: Thirty-nine normal volunteer males (mean age 58.5 +/- 18.7) and 25 females (mean age 59.4 +/- 14.1) were submitted to anorectal ultrasonography.The tissue is defined by a semiautomatic procedure. Measurements of thickness, length and volume were assessed automatically.The software provides an average number of 57,600 thickness measurements, 360 length measurements for each zone (90 for each quadrant) and seven volume measurements (one for each anatomical area). The mean values of magnitudes were calculated for the entire volume in each quadrant and zone. Age and gender-related variations were analyzed.Results: In assessments of the whole tissue, only thickness was gender-related, with greater thickness for females (male thickness: 1.81 +/- 0.47 mm, female thickness 2.16 +/- 0.57 mm, P-value < 0.01). In the distal zone: thickness, length and volume were all larger in females (for male and female respectively: 1.83 +/- 0.49 mm vs 2.34 +/- 0.58 mm, P-value < 0.01, for the thickness; 10.87 +/- 2.10 mm vs 12.18 +/- 2.21 mm, P-value < 0.02 for the length and 1501 +/- 605 mm(3) vs 2169 +/- 871 mm3, P-value < 0.01 for the volume). In the medial zone, only thickness was gender-related, with greater thickness in females (male thickness: 2.04 +/- 0.60 mm, female thickness: 2.44 +/- 0.74 mm, P-value < 0.02). The only variation observed in the proximal zone concerned length, larger in males (respectively: 11.27 +/- 2.84 mm vs 9.55 +/- 2.43 mm, P-value < 0.02).The male population was significantly positively correlated with ageing for volume in the whole tissue (rho = 0.32, P-value < 0.05), and for both thickness and volume in the medial zone (rho = 0.33, P-value < 0.05 for thickness; rho = 0.39, P-value < 0.02 for the volume). Conclusion: This new method is useful to understand both functional anal disorders and local damage which may affect only part of the muscle tissue. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

AIM:Extramammary Paget's disease is a rare neoplastic condition, often associated with a synchronous or metachronous underlying skin or visceral malignancies. The aim of this study was to evaluate retrospectively the results we got in 5 cases of perianal Paget's disease and to revise what literature have reported about this issue.PATIENTS AND METHODS:Five patients with perianal EMPD were consecutively treated in our Division between March 1996 and December 2006. In 3 cases the disease was limited to the epidermidis, in one case with multiple recurrences there was dermal infiltration, and one patient had a low rectal adenocarcinoma with pagetoid phenomenon. The surgical treatment we performed in all patients was a wide perianal excision, followed by reconstruction with cutaneous grafts; the resection of rectal adenocarcinoma was carried out using the transanal approach. In two cases we performed a temporary stoma with the sigmoid colon to help the wound healing.RESULTS:We didn't record any complication neither postoperative nor at long time. Two patients developed a local recurrence, but none of our patients showed distant metastases. Four patients are alive and free from disease and one, who developed a multiple local recurrences, died for heart failure.DISCUSSION:The studies available in literature clearly distinguish between a primary EMPD (intraepidermal/intradermal) and secondary disease which is associated with anorectal adenocarcinomas and is thought to be a pagetoid phenomenon, while few informations can derive from those cases in which the disease is associated with an underlying cutaneous adnexal carcinoma. Disease tend to relapse even after a radical surgery and can have metastatic spread, also in intraepidermal form.CONCLUSIONS:Perianal EMPD is a complex disease, difficult to recognize and the association with synchronous or metachronous malignancies imposes long term clinical and instrumental follow up.

Obiettivo. La malattia di Paget extramammaria (EMPD) e una neoplasia molto rara che frequentemente si associa a carcinomi cutanei o viscerali, sincroni o metacroni. Obiettivo dello studio e valutare retrospettivamente i risultati ottenuti in 5 casi di malattia di Paget perianale osservati e rivedere la letteratura sull’argomento. Pazienti e metodi. Cinque pazienti con EMPD perianale sono stati trattati presso la nostra Divisione da marzo 1996 a dicembre 2006. In 3 casi la malattia era confinata entro l’epidermide, in un caso plurirecidivo era presente un’infiltrazione del derma e un paziente presentava un adenocarcinoma del retto inferiore con diffusione pagetoide. I pazienti sono stati sottoposti ad ampie exeresi perianali e ricostruzioni con graft cutanei. L’asportazione dell’adenocarcinoma del retto e stata realizzata per via transanale. In due casi e stata eseguita una sigmoidostomia di protezione per favorire la guarigione della ferita. Risultati. Non si sono verificate complicanze postoperatorie, neanche a distanza. In due casi la malattia ha recidivato localmente, ma nessun paziente ha presentato metastasi a distanza. Quattro pazienti sono vivi e liberi da malattia, mentre un paziente con recidiva di malattia e deceduto per insufficienza cardiocircolatoria. Discussione. L’analisi della letteratura consente un’identificazione chiara della EMPD primitiva (intraepiteliale/intradermica) e della forma associata ad adenocarcinomi anorettali, interpretata come diffusione pagetoide. Poche informazioni sono invece ricavabili nei casi in cui la malattia si presenta come adenocarcinoma degli annessi. La malattia tende a recidivare anche dopo chirurgia exeretica radicale e ha capacita metastatizzanti, anche nella forma in situ. Conclusioni. La malattia di Paget perianale e una patologia complessa e difficile da diagnosticare. L’ associazione con carcinomi sincroni o metacroni impone follow-up lunghi con controlli clinici e strumentali frequenti.

PURPOSE:The coexistence of abdominal aortic aneurysm (AAA) and cancer is observed with increasing frequency, raising several questions about therapeutic and surgical strategies for management of both diseases. In this study, we present our experience on 14 patients affected by both colorectal cancer (CRC) and AAA, and we have also reviewed the literature from 1988 to 2005 for clinical experiences on this matter.MATERIALS AND METHODS:From January 1988 to May 2006, 1,012 AAA and 1,480 CRC were observed and treated in our department; in 14 patients (1.3% of AAA and 0.9% of CRC), both diseases were coexistent. We also performed a literature review from 1987 to 2005, and we found 254 cases of AAA associated with CRC.RESULTS:Priority was given for treatment of vascular disease. The diseases were treated in one stage in nine cases and in two stage in four patients; in the remaining case, only the CRC was treated due to patient's poor cardiac conditions. Postoperative (30-day) complications were seen in 1 of 14 patients (7.1%), whereas there were no postoperative deaths or prosthetic infections. In the literature review, treatment in one stage was performed in 102 cases and in two stage in 118 cases; in the remaining 25 cases, only one disease was treated (in 24 cases, for different reasons, only CRC was treated, whereas in the last case, only the AAA was treated, and the patient died in the postoperative period). Postoperative (30-day) morbidity and mortality in one-stage treatment were 8 and 4.5%, respectively, and 21.3 and 6% in two-stage treatments, respectively. In patients treated for only one disease, 30-day morbidity and mortality were 4 and 24%, respectively. Only one case of prosthetic infection was reported after a two-stage treatment.CONCLUSIONS:From the analysis of the literature and our experience, it is evident that, when AAA and CRC are coexistent with preoperative diagnosis of both diseases, single-stage intervention, when feasible for patient in general and local conditions, has to be preferred due to the lower morbidity. Single-stage treatment avoids a second surgical and anesthesiologic trauma and eliminates the risks joined with the non-treated lesion, increasing, however, the magnitude of the operation. Endovascular therapy, for its less invasiveness, appears to be an adequate solution for one-stage treatment of the two diseases but its role is still subject of ongoing discussions.

Colon cancer metastases rarely involve the spleen; in the literature only 29 cases of isolated splenic metastasis of colon cancer are reported (9 in the English literature and 29 in the Japanese literature). In this paper, a further case of isolated splenic metastasis in a 73 year- old woman, treated six years before with left emicolectomy for a mucinous colon cancer (Dukes B) is reported. A survey of the English literature shows that most of the cases had a significant period between the first original resection and the diagnosis of spleen metastasis (2-11 years). Splenectomy was performed in all the cases reported. No long-term follow-up has been published; therefore, it is not possible to define if spleen metastases of colon cancer have a better clinical behaviour than hepatic metastases and if splenectomy can prevent metastatic spreading of the disease leading to a potential survival benefit.

BACKGROUND AND STUDY AIMS:For several years now there has been an increasingly widespread use of a tissue adhesive in the treatment of bleeding gastric varices to achieve rapid, safe control of hemostasis and prevent rebleeding. In this study we report on our experience with the use of Bucrylate (Hystoacryl) for the treatment of gastric varices over a period of more than a decade.PATIENTS AND METHODS:Since 1988, 174 cirrhotic patients with actively bleeding gastric varices have been admitted to our department, where they received emergency treatment with injections of Bucrylate. Any associated nonbleeding esophageal varices were subjected to traditional sclerotherapy in combination with the Bucrylate treatment. The gastric varices were subdivided into four distinct groups according to the method advocated by Sarin in 1989. The patients underwent weekly sclerotherapy sessions until their varices were eradicated, and the follow-up with a mean of 36 months (range 9-90 months) consisted of endoscopy at 3, 6, and 12 months during the first year and then yearly checks to confirm obliteration of the varices.RESULTS:The hemostasis (97.1%), early rebleeding (15.5%), and hospital mortality (19.5%) rates of the patients with bleeding gastric varices, treated with the tissue adhesive, were very similar to those of patients treated for esophageal varices over the same period (98.1%, 13.0%, and 16.4%, respectively). The most frequent cause of death at 30 days was liver failure (76% of cases), followed by hemorrhagic shock (8.8%), and other less frequent causes. Sclerotherapy achieved obliteration rate for gastric varices (70-75%) similar to that for esophageal varices in those patients with portal hypertension due to intrahepatic block (alcoholic and posthepatitis cirrhosis), but a rate of only 32% in the group of patients with prehepatic block (splenoportomesenteric thrombosis), where surgery proved more effective (69%). The medium- and long-term survival rates depended on the stability of the patients' liver conditions, on rapid, effective control of variceal hemostasis, and on complete, lasting obliteration of the gastric varices.CONCLUSIONS:The use of Bucrylate in emergency sclerotherapy achieved results in bleeding gastric varices on a par with those obtained in esophageal varices in cases of alcoholic and posthepatitis cirrhosis. The group of patients with portal hypertension due to prehepatic block (splenoportal thrombosis) showed no benefit from sclerotherapy in terms of obliteration of gastric varices, but benefited from elective surgery. The choice of the obliterating treatment indicated may be facilitated by classifying gastric varices into distinct groups on the basis of anatomicotopographic criteria.

BACKGROUND AND AIM:The latest reports using transrectal ultrasound (TRUS) for the preoperative staging of rectal cancer show a diagnostic accuracy between 78 and 97% with regard to the local spread of disease, and between 62 and 86% for the diagnosis of lymph node metastasis. The correct choice of surgery depends on correct preoperative staging, as does the indication for any preoperative neoadjuvant treatment. The aim of this study was to evaluate the diagnostic precision of the method used by the authors since 1993 by comparing the preoperative transrectal ultrasound stage (uTMN) with the postoperative histological stage (pTNM). In addition, the study aimed to assess whether some anatomic and pathological characteristics of the neoplasm (differentiation, type of growth and presence of peritumoral inflammatory reaction) influenced the diagnostic precision of transrectal ultrasonography.METHODS:Forty-two patients with a preoperative histological diagnosis of adenocarcinoma localised in the rectal segment, extending up to 10 cm from the dentate line, undergoing radical surgical were selected from the group of patients with middle-lower rectal cancer studied preoperatively with TRUS. Preoperative TRUS was carried out in 42 cases by a single examiner. Anatomic and pathological examination of the removed portion was performed by examiners who were not familiar with the preoperative ultrasonographic diagnosis.RESULTS:In this study TRUS showed a diagnostic accuracy of 81% in the study of T and 71.4% in the study of N. In line with other studies, the most frequent diagnostic error was the overstaging of stage T2 tumours. Moreover, the presence of a peritumoral inflammatory reaction was found to be the only variable that significantly influenced the diagnostic accuracy of TRUS.CONCLUSIONS:TRUS was found to be a valid instrument for the preoperative staging of rectal cancer even in this preliminary study limited to 42 cases, in particular with regard to wall invasion. The limits of this method are linked to the presence of phenomena producing a situation of local infection (recent biopsies, radiotherapy, peritumoral inflammatory infiltrate) given that this prevented the correct visualisation of the layers of the rectal wall. As a result, this may limit its use in the re-staging of patients undergoing preoperative radiotherapy.

BACKGROUND:The aim of the present study was to evaluate the incidence of abdominal lymph node involvement of adenocarcinoma of the gastric cardia in relationship with the site and depth of tumor invasion.METHODS:From July 1988 to April 1998, 79 patients with adenocarcinoma of the gastric cardia underwent surgical curative resection and D2 lymphadenectomy at the 1st Department of General Surgery of Verona University. Among these 79 patients, 16 had an adenocarcinoma of the distal esophagus (type I), 26 patients had an adenocarcinoma of the anatomic cardia (type II) and 37 had a subcardial adenocarcinoma (type III). The frequency of lymph node involvement in each of the lymph nodes as classified by the JRSGC were analyzed.RESULTS:In type I carcinoma positive lymph nodes occurred in 20% of pT1, 33% of pT2 and 100% of pT3. Positive nodes along the lower half of the stomach were never found. In type II carcinoma positive lymph nodes occurred in 57% of pT1, 86% of pT2 and 83% of pT3. Metastasis along the greater curvature in 18% of advanced cancers were found. In type III carcinoma positive lymph nodes occurred in 83% of pT2, 94% of pT3 and in 100% of pT4. Nodes along greater curvature were involved in 21% of advanced cases and also infrapyloric lymph nodes involved in 13% of cases. The type II and III advanced tumors had involved paraortic lymph node in 33% of cases.CONCLUSIONS:These results suggest that for tumors of the cardia an extended lymphadenectomy is necessary to ensure the removal of all metastatic nodes.

The management of simultaneously occurring abdominal aortic aneurysm and malignancy is controversial. It is unclear whether to treat the aneurysm first or the malignancy, or both simultaneously. If the malignancy is resected first there is a risk of postoperative rupture of the aneurysm. If simultaneous surgery is performed there is a risk of prosthetic graft infection. This condition leads to many therapeutic problems which, by the light of 18 personal cases occurred in almost ten years and the recent literature, are discussed in this paper.

The infected aneurysms of the aorta represent the 0.65% of all the aneurysms and they are associated with high morbidity and mortality. The vascular infections from Salmonella are not particularly frequent, even if in the last years their reports are more numerous. The authors report their experience in the surgical treatment of one case of aneurysm of the abdominal aorta infected by group C Salmonella, making a review of the Literature on this matter.

Mycotic endocarditis has an incidence of 6.7% of all the forms of endocarditis and in 33-75% of the cases it complicates with peripheral embolization, more frequently to the lower limbs. Although the prognosis of the mycotic endocarditis is improved in the last years, it remains particularly serious especially when it's associated with arterial peripheral embolization. The authors report their experience in the surgical treatment of one case of occlusion of the iliac artery secondary to mycotic endocarditis, making a review of the Literature on this matter.

Neurilemmoma and Neurofibroma are benign tumours of the peripheral nerves that originate from the Schwann Cells. The finding of these tumours in the gastrointestinal tract in absence of generalized neurofibromatosis is uncommon and their presence in the anorectal area is extremely rare. From review of the literature we found only 34 cases of anorectal neurilemmoma. We report two patients, one with a rectal neurilemmoma and another with a perianal neurofibroma without a coexisting Von Recklinghausen's disease in either. In both cases they were asymptomatic and the surgical procedure performed was the simple tumorectomy which was diagnostic and curative. The literature on this subject is reviewed with particular attention to the possible malignant degeneration and the choice of the surgical approaches.

The aneurysms of the celiac trunk are the rarest aneurysms of the visceral arteries. From 1958 only 69 cases have been reported in the international literature. They are frequently asymptomatic and their discovery is more often occasional. They can rupture in 15-20% of the cases with a mortality approaching 80% of the cases. This explains the need of a surgical treatment even in the asymptomatic cases. Personal experience in the surgical treatment of a case of aneurysm of the celiac trunk is reported and a survey of the literature on this matter is made.

Since 1985, when Hardy [1] first introduced the Valtrac biofragmentable anastomosis ring (BAR; Davis and Geck, Wayne, NJ, USA) for end-to-end colocolic anastomoses, many clinical studies have confirmed the safety of this device compared to stapled and sutured anastomoses [2—6]. The postoperative and long-term complication rate has proven to be comparable to the other anastomotic techniques, and the use of this device has recently been extended to the upper gastrointestinal tract.

Duodenal diverticulum is not a rare disease, with a frequency of 1-3% in radiologic review and of 2.8-20% in pathology review; The spontaneous perforation of a perivaterian duodenal diverticulum is a rare complication, with about 100 cases reported in the literature. The post-traumatic perforation of a perivaterian diverticulum is an exceptional event, reported in single cases of the oriental literature. The authors report their personal experience about two cases of diverticular duodenal perforation, one spontaneous, the other post-traumatic, discussing the surgical problems that this rare complication present.