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Orbital region may be divided into four sectors: medial canthus, lateral canthus, lower lid and upper lid. A vertical section of a lid shows 5 layers: skin, subcutaneous tissue with orbicularis muscle, fibrous layer (tarsus-aponeurosis), plain fibers muscle layer (Muller's), conjunctiva. The first two layers form the "anterior lamella" and the other ones the "posterior lamella", divided by the grey line. In this review Authors describe with all details the orbital region and the eyelid layers, considering the most important concepts for surgery. Finally they resume basics of local anesthesia in ophthalmoplastic surgery.

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In the orbital region the variety of tumors is so vast that even an expert oculoplastic surgeon may be deceived. The various tumors may be classified as benign, precancerous and malignant. Approximately 5-10% of all skin cancers occur in the eyelids. Incidence studies indicate that basal cell carcinoma is the most frequent malignant eyelid tumor, followed by squamous cell carcinoma, sebaceous gland carcinoma and malignant melanoma. Malignant neoplasms represent the leading cause of plastic reconstruction in orbital region, followed by cicatricial retraction, post-traumatic loss of tissue, congenital colobomas. Aim of this review is to classify benign and malignant lesions; to consider the surgical removal approach to the lesion (Mohs micrographic surgery, frozen sections, biopsy, immediate removal and reconstruction with permanent sections) and finally to consider reconstruction techniques with grafts and flaps.

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Aim of this review was to describe ectropion, entropion and trichiasis and their therapy. These eyelid pathologies are characterised by common symptoms (redness, excessive tearing and irritation of the eye) and by altered balance of the anterior and posterior lamellae of the eyelids. They involve more frequently the inferior eyelid and the therapy is mainly surgical. Parasurgical therapy may play a role as a temporary measure.

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Blepharoptosis of the upper eyelid is a common condition among patients presenting for oculoplastic surgery. Although there are many types of ptosis, the two most frequent clinical cases are simple congenital ptosis in young patients and senile ptosis in adults. Patient examination is important to distinguish these from other more infrequent types of ptosis, such as those neurogenic, myogenic and posttraumatic. These latter cases may require specific therapeutic strategies. Ptosis can usually be corrected surgically. The article discusses guidelines for the choice of intervention. Various different surgical techniques are also presented, together with results and complications.

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In the periorbital the major aging changes are a drooping of the brow (brow ptosis), excessive accumulation of skin in the upper lid (dermatochalasis), and a prolapse of orbital fat, in the upper and lower lids caused by weakening of the septum and orbital connective tissues. The specific anatomical abnormalities of each individual patients should be identified and the relationship between each other should be identified in order to determine a correct surgical plan. In this review we will analyze different surgical techniques.

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BACKGROUND: Representing the second cause of cancer-related death after lung cancer in men and breast cancer in women, colorectal cancer (CRC) is a major health problem in Italy. Obesity is reckoned to favor CRC; however, the underlying mechanisms are unclear. Recently, a single nucleotide polymorphism (SNP) in the fat mass and obesity associated (FTO) gene was found to be significantly associated with obesity. AIMS: To establish whether the FTO SNP rs9939609 may represent a risk factor for CRC and adenoma in the Italian population. PATIENTS AND METHODS: 1,037 subjects were enrolled in the study and divided in 3 groups: CRC (341 pts., M/F=197/144, mean age=65.17±11.16 years), colorectal adenoma (385 pts., M/F=247/138, mean age=62.49±13.01 years), healthy controls (311 pts., M/F=150/161, mean age=57.31±13.84 years). DNA was extracted from whole blood, and stored frozen for rs9939609 genotyping by real-time PCR. RESULTS: The frequency of the obesity-associated mutated A allele (AA+AT) on the FTO gene was 69.77% among controls, and 71.85% and 65.71% respectively among CRC and polyp patients. Compared to control subjects the AA+AT genotype had no significant effect on the risk for either CRC (OR=1.106; CI 95%=0.788-1.550; p=0.561) or colorectal adenomas (OR=0.830; CI 95%=0.602-1.144; p=0.255). We did not observe any association between the AA genotype and CRC/polyp localization and age at diagnosis. As measured in a patient subset, carriership of the risk alleles did not reflect in a significantly altered BMI. CONCLUSION: The obesity-linked FTO variants do not play a significant role in modulating the colorectal cancer risk in the Italian population.

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AIM: This was a retrospective survey of 88 inflammatory bowel disease patients (43 with ulcerative colitis, 38 with Crohn's disease, 7 with indeterminate colitis) who were visited between January 2008 and June 2009 at a newly established out-patient service at a primary care hospital in Turin. METHODS: Treatments included corticosteroids (48 courses), mesalamines (79 courses), thiopurines (46 courses), and biological drugs (three treatments). With more extra-intestinal manifestations, more steroid needs, more visits and more surgeries, Crohn's proved more fastidious than ulcerative colitis. All of the drugs used gave side-effects that required skillful action for control: switch to mercaptopurine was advantageously used to react to azathioprine intolerance. RESULTS: Percentages of steroid needs, of stable remission, and resort to surgery were 30, 50, <20 and 40, 27, 30, respectively in ulcerative colitis and Crohn's. Thiopurines played a crucial role in the maintenance of remission of ulcerative colitis: the patients maintaining remission in the absence of azathioprine had either been resected or had left-sided disease only; left-sided disease proved also fairly responsive to beclomethasone. The unusual conduction of this service by a single doctor caused an increased trust-in-physician, but also more bias and placebo effects as drawbacks. CONCLUSIONS: The results suggest that in the last 30 years management of inflammatory bowel disease has still improved mainly due to refinement of the use of traditional drugs.

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AIM: Third-level Day-Hospital Services of Gastro-Hepatology are likely to recruit patients with an increased disease severity. The burden of request for immunomodulation drugs is presently unclear. METHODS: The charts of 1 012 consecutive patients who underwent day-hospital admission were reviewed. Among them, 975 were admitted for several reasons (percutaneous liver biopsies, abdominal fluid aspirations, infiltrations of hepatic nodules, gastrointestinal endoscopies with specific treatments). Data of the remaining 37 patients were elaborated. RESULTS: Of them, 31 (83%) suffered from ulcerative colitis (UC) or Crohn's disease (CD) (17 and 14, respectively) and 6 from autoimmune type 1 hepatitis (AIH). Of the 14 non-operated UC patients, 12 were taking azathioprine (AZA) and 2 infliximab (IFX). Among CD patients, the majority received AZA (N=6) or IFX (N=6). Of the AIH patients, 5 were treated with AZA and 2 had also cyclosporine. Overall, corticosteroids (32%) and IFX (21%) ranked first and second among the induction drugs, and AZA ranked first (62%) as maintenance option. Of the 4 CD patients under IFX treatment, 2 were switched to leukapheresis for incomplete response, the third one developed thrombotic complications, and the last one achieved disease remission after 12 months. Of the 2 cases of UC, one lost response soon and was colectomized, the other is maintaining moderately active disease, requiring scheduled injections every 8 weeks. CONCLUSION: Despite the caution imposed by the very small numbers, this analysis confirms that the potent available options are difficult to be correctly positioned in the therapeutic algorithm of inflammatory bowel disease.

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High aminotransferases and prolonged prothrombin time on entering our liver unit were revealing parenchymal collapse for this 45-year-old obese woman; treatment failure led her to death. Autoimmunity, paracetamol use, alcoholism, and Wilson's disease were all excluded as causes. Because of chronic asthma, she had been receiving a leukotriene receptor antagonist (montelukast) for 5 years before the current presentation; 1 week before onset she had had 1 week of treatment with two dietary supplements for weight control; one of these included Garcinia Cambogia, a possible cause of two recent cases of hepatitis in the USA; in addition, both formulas contained a citrus derivative that interferes cytochrome functions. We speculate on a causal relationship between the assumption of the additives and the fatal hepatitis and envisage a synergy between the additives and montelukast, which per se has well been studied as a hepatotoxic drug. Despite the speculative nature of this presentation, we believe the warning may serve to focus attention on the uncontrolled escalation of food additives going on in these days.

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The monoclonal antibody to the tumour necrosis factor--infliximab--has recently been added to the list of off-label therapeutic means for ulcerative colitis. We conducted a descriptive analysis of the results from studies on the use of the drug published so far. A total of 187 patients qualified for analysis. They were divided into four main categories, including steroid-refractory and responsive adults and children. The median frequencies of an early and a sustained response were 77 and 44.5%. These data suggest that adult non-steroid-refractory, and paediatric patients may respond with the highest frequency. While it is obligatory to wait for the yield of the ongoing controlled trials before any conclusion on these indications is drawn, the data provide seminal ideas to further investigations, including the hypothesis to inaugurate with infliximab a top-down strategy for the treatment of inflammatory bowel disease.

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AIM: The 60% bioavailable oral microemulsion formulation of cyclosporin (NEORAL ), has replaced the intravenous route to treat both organ transplant and immune-based disease. Its use for steroid-refractory ulcerative colitis (a recognized indication for intravenous cyclosporin) has been scanty. METHODS: Twenty-three consecutive patients (14 male/9 female, universal colitis 14/23) entered a 3-month course of NEORAL (initially dosed at 5 mg/kg/day) because of steroid-refractoriness (14 cases) and steroid-dependence (9 cases). Responders (at least showing a 50% reduction of a clinical activity score) were continued on azathioprine. The initial steroid dose was tapered on commencing NEORAL; patients requiring steroid resumption or increase in the follow-up were defined as relapsers. RESULTS: The target trough concentration of 200 ng/ml of whole blood was achieved without major titration in all but 1 patient. There were 7 non-responders (30%). Of the 16 responders (70%), 2 have not relapsed; the remaining 14 relapsed at the median time of 9.5 months (1.5-60) with 10 (71%) showing only 1 relapse. Five patients were colectomized 12 months after NEORAL (1.5-24), leaving 11 of the initial 23 (47%) with their colon. Of the 16, all but 1 had azathioprine; the median daily steroid needs fell from 32 to 5 mg. CONCLUSION: The rates of acute and chronic response of 70% and 47% achieved by NEORAL in this indication duplicate the figures achieved by the traditional schedules of cyclosporin administration.

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AIM: The aim of this study is to analyse the clinical course of ulcerative colitis during maintenance therapy with azathioprine, a drug which is still not proved to be able to modify the natural history of the disease. METHODS: A retrospective study is made of data regarding the frequency of hospital admission for patients with ulcerative colitis referring to a gastroenterological Day-Hospital between 1991 and 2000. The disease history of these patients has been divided into 2 sections: one preceding and the other following an index-event, identified as the beginning of a maintenance regimen with azathioprine; this allowed to find possible differences in the clinical course after the index-event. Patients were controls of themselves. RESULTS: Seventeen patients qualified for analysis. Remission from an acute severe attack of ulcerative colitis was reached by intravenous or oral cyclosporine for 14 of them and by prednisone for 3 of them. The maintenance treatment with azathioprine, which started in all but 1 patient (intention-to-treat), showed a reduction in the number of hospital admissions, decreasing from a mean of 2.12+/-0.69 in the preceding 4.2+/-4.3 years to a mean of 0.12+/-0.33 in the following 5.8+/-2.5 years (p=0.000). CONCLUSIONS: Patients undergoing maintenance therapy with azathioprine showed face fewer relapses needing hospitalisation than those without azathioprine.

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BACKGROUND: Success achieved in two subtypes of Crohn's disease has persuaded a few investigators to experiment the monoclonal anti-tumour necrosis factor antibody infliximab in the treatment of ulcerative colitis. So far, however, the results (achieved in some 30 steroid-refractory patients included in two independent full-papers) indicate a rate of initial response of 50% and of remission of 25%. AIMS: To analyse data of an open trial conducted on consecutive steroid-refractory severely ill patients admitted to our referral Unit. PATIENTS AND METHODS: In 9 months, infliximab was given to 8 patients (4 male, 4 female aged 20-60 years) with uncontrolled ulcerative colitis of whom 6 were non-responders to parenteral steroids. All received the first infliximab dose as an intravenous infusion of 5 mg/kg. RESULTS: Of the 8, 4 (50%) did not respond to the first injection and were submitted to urgent colectomy; the other four responded clinically. Two have maintained clinical remission for 7 months, without the need for steroids; both have received daily azathioprine at 2 mg/kg, and only one has received two further infliximab injections. Of the other two, one received a second injection at week 5, despite this relapsed, and underwent elective colectomy at that time; the other relapsed at 6 months and showed a partial response to a repeat infliximab infusion. Thus, the rate of sustained response is 2/8 (25%) in this study. CONCLUSION: These results, achieved in an open uncontrolled fashion, seem to reflect those of other independent studies. In our opinion, these findings warrant an in-depth reappraisal of the indication to use infliximab as rescue treatment for refractory ulcerative colitis.

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BACKGROUND: Ulcerative colitis is a chronic inflammatory disease of the colon thought to be caused by an abnormal T-cell response to lumenal antigens. In the last 10 years immunosuppressives have been proposed to treat its severe forms including cyclosporin and azathioprine. METHODS: An analysis of 72 patients treated for severe ulcerative colitis between 1991 and 2001 at our Day Hospital permitted an audit of the efficacy of this two-drug regime. RESULTS: Overall, the percentages of patients avoiding colectomy immediately, at 1 year, and on ending the study were 68, 47 and 36%, respectively. Thirty-five (81%) of the 43 colectomies, performed as a restorative procedure, clustered in the first year after disease presentation. The risk of colectomy was significantly reduced in the subset treated with azathioprine. Of the 25 long-term responder patients avoiding colectomy, to-date 16 (64%) had at least a relapse at the median time of 17.5 months; all but 1 episodes were managed on an out-patient basis. The types and frequencies of observed side-effects were within the known therapeutic profile of the two drugs. CONCLUSIONS: A two-drug regime of cyclosporin and azathioprine can avoid colectomy for 1 year in slightly less than 50% of a cohort of severe ulcerative colitis patients and permits an acceptable long-term response in slightly less than 40%. An accurate evaluation of this policy needs to be balanced with other options, including most recently refined techniques of colectomy.