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Primary small bowel tumors account for 1-6% of all Gastrointestinal (G.I.) tract malignancies. Among these pedunculated lipomas are unusual. We report a case of a 66-year-old male with a history of G.I. hemorrhage and acute anemia, negative upper and lower endoscopies and a pedunculated lipoma in distal ileum, revealed by CT enterography. The patient was successfully treated by open surgery. Patients with G.I. hemorrhage and negative upper and lower endoscopies need an accurate evaluation of small bowel. Multislice CT enterography or Magnetic Resonance enteroclysis/ enterography represent the fastest and more accurate tools to obtain an exhaustive evaluation of small bowel. In case of small bowel tumors this diagnostic procedures can show site and stage and can even suggest histological type of such neoplasms, with a significant impact in the surgical planning, avoiding time consuming surgical exploration. In this patient multislice TC enterography allowed a correct diagnosis of benign lipoma due to its radiological density and absence of infiltration of the intestinal wall and surrounding tissues. KEY WORDS: CT enterography, Gastrointestinal hemorrhage, Lipoma, Small bowel.

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Choledochal cysts are cystic dilatations of the intra or extra-hepatic biliary tract with an incidence of 1 case per 150.000 live births. Cysts usually are diagnosed in childhood, but diagnosis can be delayed until adulthood in the 20-50% of cases. Clinical manifestations comprise abdominal pain with biliary or pancreatic features. Mirizzi's syndrome is a late and rare complication, that occurs in 1% of patients with cholelithiasis due to extrinsic compression of the common bile duct by stones impacted either in the gallbladder or in the cystic duct. Clinical symptoms include extrahepatic obstructive jaundice, ascending cholangitis, or, in the later course, cholecystocholedocal fistula. For both pathologies the Endoscopic Retrograde Cholangio Pancreatography and the Magnetic Resonance Cholangio Pancreatography should lead to the diagnosis with a sensibility and a specificity up to 100%. We report the case of a 66 year old patient admitted to the Emergency Department of our hospital for jaundice and abdominal pain, whom both the endoscopic and radiologic examination showed a Mirizzi's syndrome but surgery revealed a type I choledocal cyst.

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Choledochal cysts are cystic dilatations of the intra or extra-hepatic biliary tract with an incidence of 1 case per 150.000 live births. Cysts usually are diagnosed in childhood, but diagnosis can be delayed until adulthood in the 20-50% of cases. Clinical manifestations comprise abdominal pain with biliary or pancreatic features. Mirizzi's syndrome is a late and rare complication, that occurs in 1% of patients with cholelithiasis due to extrinsic compression of the common bile duct by stones impacted either in the gallbladder or in the cystic duct. Clinical symptoms include extrahepatic obstructive jaundice, ascending cholangitis, or, in the later course, cholecystocholedocal fistula. For both pathologies the Endoscopic Retrograde Cholangio Pancreatography and the Magnetic Resonance Cholangio Pancreatography should lead to the diagnosis with a sensibility and a specificity up to 100%. We report the case of a 66 year old patient admitted to the Emergency Department of our hospital for jaundice and abdominal pain, whom both the endoscopic and radiologic examination showed a Mirizzi's syndrome but surgery revealed a type I choledocal cyst.

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BACKGROUND: Evidence-based criteria in the therapeutic choice for sigmoid acute diverticulitis (AD) are lacking. It is necessary to differentiate an acute episode of diverticular disease, not complicated (NCAD) and complicated (CAD) because these stages of diverticular disease needs different approach. METHODS: In a prospective study on 377 consecutive patients admitted for AD, 265 had NCAD and 112 CAD diagnosed with CT scan. Thirty-six of 265 with NCAD were operated on due to two or more previous episodes of AD. On 188 patients with NCAD followed-up, 35 had further episodes of NCAD and 2 had CAD. On 112 CAD patients, 61 had Hinchey I and were submitted to colonic resection. Twenty-three of 24 patients with Hinchey II were treated with percutaneous drainage. All Hinchey II patients were operated on. All the 13 patients with Hinchey III and IV had emergency surgery. RESULTS: We had no mortality and respectively 9.8% and 30% morbidity in Hinchey I and II patients. In Hinchey II patients percutaneous drainage was successful in 21 on 23 (91.3%). In 13 Hinchey III and IV patients the mortality rate was 25%. The comparison of CT findings and pathological results showed a sensitivity of 100% and predictive positive value of respectively 94.4, 96.7, 100 and 100% for NCAD, Hinchey I, Hinchey II and Hinchey III-IV. CONCLUSIONS: The therapeutic approach of diverticular disease needs to differentiate among an acute episode, NCAD and CAD. Evidence-based therapeutic choices can be reached only by homogeneous diagnostic criteria obtained by CT scan.

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PURPOSE: The role of MR enteroclysis/enterography (MRE) in the diagnosis of small bowel (SB) tumor has not been fully evaluated. The aims of this study were to assess the capability of MRE correctly identifying the site, stage and histology of such neoplasms. METHODS: MR enteroclysis/enterography was employed in consecutive patients suspected of having an SB tumor following negative upper and lower endoscopies. The SB was subdivided into proximal jejunum, middle SB and distal ileum. The histological examination (HE) of the surgical specimen was the reference standard. RESULTS: One hundred and fifty-eight patients were examined. Thirty-one out of 32 (96.9 %) SB detected by HE were correctly identified by MRE. The concordance rate between MRE and HE was 100 % for localization, and 87.1, 80.6 and 96.8 % for T, N and M stages, respectively. The concordance rate was 62.2 % for histological diagnosis. CONCLUSIONS: The high concordance rates between MRE and HE for the localization of SB tumors and for their staging have a significant impact upon surgical planning, particularly if laparoscopy is being considered. A preoperative histological diagnosis is not sufficiently reliable.

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AIM: To value the results of "open" surgery with sphincter preservation, TME nerve-sparing, fast-track, without a protective stoma in a consecutive series of patients with subperitoneal rectal cancer (s.p.r.c.). MATERIALS AND METHODS: In January 1989, we started a prospective, non-randomized study designed to assess when a primary derivative stoma was warranted in a series of consecutive patients electively treated with open low and ultralow AR. The inclusion criteria were: all patients with middle and low rectal cancer who underwent elective low and ultralow AR, including those treated with neoadjuvant therapy. The exclusion criteria were: urgent surgery, incomplete rings in the stapler, a positive hydropneumatic test, preoperative involvement of the external sphincter and/or surrounding structures by the tumor as demonstrated by CT-scan and endorectal MR and/or transrectal ultrasound. Anastomoses between 7 cm and 4 cm from the pectinate line were defined as low colo-rectal anastomoses, while anastomoses lower than 4 cm from the pectinate line were defined as ultralow anastomoses. A fistula or anastomotic dehiscence was suspected when pelvic and/or peritoneal pain, fever, leucocytosis, fecaloid liquid in the drainage and/or perianal erythematosus swelling were present. An anastomotic leak was confirmed by means of angio-CT and/or endoscopy and/or contrast enema depending on the procedure available most promptly. Signs of peritoneal reaction were considered to be indicative of a major dehiscence, regardless of the diameter of the fistula; when diagnosed, a transverse colostomy was immediately performed. Clinically less serious cases were defined as minor dehiscences, for which a "wait and see" strategy or a transcutaneous CT or ultrasound guided drainage of an abscess were used. Sixty-five patients were treated according to a fast-track postoperative protocol. RESULTS: Between 1998 and 2007, 89 patients with s.p.r.c. were treated according to a prospective protocol. One hundred and nineteen patients (69.6%) underwent low anastomoses and 52 patients (30.4%) underwent ultra low anastomoses. Forty-two (24.6%) were treated with traditional AR, 129 (75.4%) with AR and nerve-sparing TME. Forty-six (26.9%) patients underwent neoadjuvant therapy. One hundred and two patients underwent a mechanical end-to-end anastomosis, 67 a double stapled anastomosis, and 2 a colo-anal anastomosis at the pectinate line performed according to our technique. All 6 patients with major dehiscences underwent a protective colostomy within hours of the onset of clinical symptoms immediately after the radiologically- or endoscopically-confirmed diagnosis. The 7 minor dehiscences were successfully treated with conservative therapy (antibiotic and enteral feeding) using an out-patient regimen. Two (28.6%) required percutaneous drainage: one pelvic CT-guided drainage and the other (an ultralow dehiscence) perineal drainage. The 72.6% of the patients survived at 5-years follow-up. The incidence of local recurrences in 2-years followup was 3.2% (on 124 patients). We had no deaths in patients treated with fast-track protocol. CONCLUSION: Open, TME nerve-sparing A.R. with selective use of neoadjuvant therapy, can be successfully performed without a protective stoma in more than 80% of the patients. Fast-track protocol seems to increase quality of p.o. period and decrease hospital stay

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A questionnaire including 20 questions about different aspects of subperitoneal rectal cancer was sent to 2200 fellows of Italian Society of Surgery. The answers were compared with International guidelines and with more recent metaanalyses from the literature. On the whole less than half of Italian surgeons fulfil the terms of the guidelines and the prevalent trend of the International literature. This behaviour concerns the choice of surgical procedure and prevention and diagnosis of anastomotic fistulas.

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BACKGROUND: Upper and lower acute gastrointestinal bleeding (AGIB) is associated with high rates of mortality and morbidity. The latest computerized tomography (CT) imaging techniques play an important role in the treatment of this pathology. METHODS: Twenty-nine patients with severe AGIB (11 upper, 18 lower), all hemodynamically stable, underwent endoscopy followed by a multi-detector row CT (MDCT) scan. Endoscopic and MDCT accuracy for the anatomical localization and etiology of AGIB was assessed, the diagnosis being considered correct when the two procedures were concordant or when the diagnosis was confirmed by angiographic, surgical, or post-mortem findings. RESULTS: The sensitivity in identifying the site and etiology of bleeding was, respectively, 100% and 90.9% for the MDCT scan, compared with 72.7% and 54.5% for endoscopy in upper AGIB, and 100% and 88.2% for the MDCT scan, compared with 52.9% and 52.9% for endoscopy, in lower AGIB. CONCLUSIONS: Considering the advantages of MDCT over endoscopy, we propose a new diagnostic algorithm for AGIB.

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AIM: Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm, its preoperative diagnosis is difficult and therefore inappropriate therapy or postoperative complications are frequent. Reviewing the literature, the purpose of this article was to identify guidelines to improve diagnosis and treatment of SPT. CASE REPORT: Authors report a case of SPT of the pancreas in a 27-year-old woman in whom a mistaken radiologic diagnosis made surgical strategy difficult and caused postoperative complications. DISCUSSION/CONCLUSIONS: Clinicians and surgeons should: (1) consider the possible disease of SPT in young females, with pancreatic encapsulated lesion with well-defined borders and variable central areas of cystic degeneration, necrosis or hemorrhage showed on radiological examinations. (2) Intensity of the differentiation of the clinical symptoms, especially during the course of therapy of chronic gastritis and diabetes. (3) Use immunohistochemical stains of alpha-1-antitrypsin, alpha-1-antichymotrypsin, vimentin and neuron-specific enolase. (4) Keep this unusual but potentially curable tumor in mind, following patients who had suffered from acute pancreatitis or abdominal injury. Increasing experience with this tumor leads to a greater awareness of its clinical presentation and pathological features and a lower rate of misdiagnosis. (5) Finally, perform, where technically feasible, conservative surgical treatment, that is safe and effective.

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The aim of the study was to evaluate the results of open surgery with sphincter preservation and nerve-sparing total mesorectal excision and a fast-track protocol, without a protective stoma in a consecutive series of patients with extraperitoneal rectal cancer. From 1998 to 2007, 89 patients with extraperitoneal rectal cancer were treated according to a prospective protocol. Eight-six patients were submitted to anterior resection with a low or ultra-low anastomosis and nerve-sparing total mesorectal excision. Fifty-four patients received neoadjuvant therapy. Twenty-eight patients were treated according to a fast-track postoperative protocol. Primary protective colostomies were performed in 6 cases (6.9%), while a secondary colostomy was necessary in 3 patients (3.4%). There was just one postoperative death (1.1%) and major morbidity occurred in 12.3%. Seven patients developed anastomotic dehiscence; 3 were successfully treated with a secondary colostomy and 4 were treated conservatively. 68.4% of the patients treated with the fast-track protocol could be discharged on postoperative day 4. 73% of patients were still surviving at a 5-year follow-up (48 patients). The incidence of local recurrences was 3.1%. Anterior resection in the form of open nerve-sparing total mesorectal excision with selective use of neoadjuvant therapy can be successfully performed without a protective stoma in more than 80% of patients. The fast-track protocol seems to increase the quality of the patient's postoperative condition and reduce the hospital stay.

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