Giovanni Alemanno

Multiphoton morpho-functional imaging of healthy colon mucosa, adenomatous polyp and adenocarcinoma.

Two-photon spectral resolved imaging was used to image fresh human biopsies of colon tissue and to characterize healthy colon mucosa, adenomatous polyp and adenocarcinoma by means of a morpho-functional analysis. Morphological examination, performed using endogenous tissue fluorescence, discriminated adenomatous and adenocarcinoma tissues from normal mucosa in terms of cellular asymmetry and nucleus-to-cytoplasm ratio. Good agreement was found between multiphoton images and histological examination performed on the same samples. Further characterization, performed by means of spectral-resolved analysis of NADH and FAD fluorescence, demonstrated an altered metabolic activity in both adenomatous and adenocarcinoma tissues compared to healthy mucosa. This morpho-functional approach may represent a powerful method to be used in combination with endoscopy for in vivo optical diagnosis of colon cancer and may be extended to other tissues.

Symptomatic duodenal Crohn's disease: is strictureplasty the right choice?

Primary duodenal localization of Crohns disease (CD) is rare. Medical therapy can control symptoms, but surgery is required when progressive obstructive symptoms occur. Surgical options include bypass, resection, or strictureplasty, but it is still not clear which should be the treatment of choice. Reviewing the medical records of 1253 patients undergoing surgery for CD between January 1986 and December 2011 at the Digestive Surgery Unit of the Department of Clinical Physiopathology of the University of Florence, 10 patients (6 males and 4 females) underwent operations for duodenal CD. Four patients had only a duodenal localization, 6 patients had synchronous involvement of other intestinal tracts. Strictures were distributed in all the duodenal portions: in 7 patients there were single lesions, in 3 patients there were multiple lesions. Eight patients were treated with strictureplasty: 5 with the Heineke-Mikulicz technique, 2 with Jaboulay, and 1 with a pedunculated jejunal patch. Two patients were treated with resection: one with a B2 gastro-duodenal resection, and 1 with a duodenal-jejunal resection and an end to side duodeno-jejunal anastomosis. Follow up of the patients was from 2 to 18 years. No recurrence of duodenal CD was observed in the 2 patients treated with resection, while 2 of the 8 patients treated with strictureplasty had a recurrence. In our experience, strictureplasty is indicated when less than 2 strictures are present in the 2nd or 3rd duodenal portion. In cases with multiple strictures localized in the 1st or the distal duodenal portion, resection is preferable.

Median Arcuate Ligament Syndrome in a patient with Crohn's disease

INTRODUCTION The Median Arcuate Ligament Syndrome is a rare condition characterized by postprandial abdominal pain, bowel function disorder and weight loss. We report the first case to our knowledge of Crohns disease and Median Arcuate Ligament Syndrome. PRESENTATION OF CASE The patient was a 33 year-old female with a previous diagnosis of Crohns disease. Acute postprandial abdominal pain affected the patient every day; she was, therefore, referred to US-Doppler and magnetic resonance angiography of the abdominal vessels and received a diagnosis of Median Arcuate Ligament Syndrome. Consequently, the patient was surgically treated, releasing the vascular compression. After the operation, she reported a complete relief from postprandial pain which was one of her major concerns. Subocclusive symptoms occurred after six months due to the inflammatory reactivation of the terminal ileitis. DISCUSSION The diagnosis of Median Arcuate Ligament Syndrome is mainly based on the exclusion of other intestinal disorders but it should be always confirmed using noninvasive tests such as US-Doppler, angio-CT or magnetic resonance angiography. CONCLUSION This case demonstrates that the Median Arcuate Ligament Syndrome could be the major cause of symptoms, even in presence of other abdominal disorders.

Combination of diagnostic laparoscopy and intraoperative indocyanine green fluorescence angiography for the early detection of intestinal ischemia not detectable at CT scan

Highlights • The recognition of intestinal ischemia often occurs too late due to the presence of unspecific symptoms and lack of reliable exams.• The combination of laparoscopy and UV light and fluorescein dye should be considered as an invaluable procedure for the early diagnosis of acute bowel ischemia.• ICG can intraoperatively provide more useful information than conventional clinical assessment, mostly in case of a non-diagnostic CT scan.

A multidisciplinary approach to desmoid tumors. When intra-abdominal fibromatosis degenerates into an abscess, which is the right treatment?

INTRODUCTION Desmoid tumors are rare benign tumors that originates in the fibrous sheath or musculo-aponeurotic structure. Histologically benign, they tends to invade locally and to be recurrent. PRESENTATION OF CASE We report a rare case of an intra-abdominal desmoid tumor in a patient affected by familial adenomatous polyposis, which degenerated into abscess. Male, 38 years, was hospitalized for abdominal pain, bowel obstruction and fever. The computed tomography showed a big dishomogeneous mass occupying the whole mesentery with internal massive liquefaction. The mass extended from the epigastrium for 13cm up to L3. On the right mesogastric side a solid, thick mass of about 2cm, with a length of 4.5cm, was identified; it was not cleavable from the wall and from some of the loops. We decided to perform a computed tomography-guided percutaneous drainage. Two hundred ml of purulent necrotic material was aspirated, and washing with antibiotic solution was carried out. Cytological examination of fluid drainage showed histiocytes and neutrophils. At follow-up, the patients clinical condition had improved. An abdominal ultrasound showed a substantial reduction in the diameter of the mass. DISCUSSION Diagnosis and treatment of desmoids tumor in patients with familial adenomatous polyposis may be difficult, especially when desmoids are located intra-abdominally and in the mesentery. Seldom will desmoid tumors be complicated by abscess formation. CONCLUSION The management of desmoids tumors is not easy and the choice of the best treatment may be difficult due to the different possible anatomical presentations.

Adrenalectomy: indications and options for treatment

The history of adrenal surgery is longstanding. Firstly described in 1889 by Thornton, the open adrenalectomy has been for decades the only surgical approach to adrenal diseases. Nowadays, instead, several approaches to adrenal glands have been described in the literature, such as laparoscopic adrenalectomy, robotic-assisted procedure and single-incision technique. Actually, laparoscopic adrenalectomy is considered as the gold standard treatment for adrenal lesions. In fact, all functional tumors, including pheochromocytoma, are candidates for a laparoscopic approach in the absence of other contraindications. In the adrenal gland surgery, it is important to consider that a multidisciplinary approach which comprises surgeons, anesthesiologists, endocrinologists, and oncologists plays an important role in the management of patients and that the success of the procedure is related also to surgeon experience and hospital volume. This review aims to discuss the indications for adrenalectomy and to describe the different techniques options for the adrenal gland surgery.

Resolving sphincter of Oddi incontinence for primary duodenal Crohn's disease with strictureplasty

INTRODUCTION Crohns involvement of duodenum is a rare event and may be associated to proteiform symptoms and uncommon pathological aspects which make diagnosis and treatment complex. PRESENTATION OF CASE The peculiar aspect of this case was a suspected duodeno-biliary fistula. The patient (female, 22 years old) was affected by duodenal Crohns disease. Magnetic resonance imaging showed a dilated common bile duct, whose final part linked to a formation containing fluid, and characterized by filling of the contrast medium in the excretory phase. Abdominal ultrasound showed intra-hepatic and intra-gallbladder aerobilia. At surgery, the duodenum was mobilized showing an inflammatory stricture and a slight dilatation of the common bile duct, with no signs of fistulas. The opened duodenum was anastomized side to side to a transmesocolic loop of the jejunum. After surgery, the general condition of the patient improved. DISCUSSION Only two cases of fistula between a narrow duodenal bulb and the common bile duct have been described in literature and the Authors were not be able to verify the occurrence of a duodenal biliary fistula at surgery. The association between duodenal Crohns disease and Sphincter of Oddi incontinence is a very rare finding with different etiology: chronic intestinal pseudo-obstruction, common bile duct stones, progressive systemic sclerosis. CONCLUSION The treatment to resolve Sphincter of Oddi incontinence for primary duodenal Crohns disease is not clear. Strictureplasty could be the treatment of choice, because, resolving the stricture, the duodenal pressure is likely to decrease and the reflux through the incontinent sphincter can be avoided.

Comparing outcomes after treatment of rectal cancer over a long-lasting follow-up between patients who were offered to surgery alone and to surgery with neoadjuvant therapy. A single center survey up to 240 months

BACKGROUND To assess outcomes of patients operated on for rectal cancer (RC) by analysing the trends of disease free survival curves (DFSc) after a very long-term follow-up. METHODS All patients treated with curative intent for RC from 1986 to 2005 were retrospectively analyzed. Other than demographics, disease characteristics and treatment-related factors were considered. The DFSc were compared between patients who had neoadjuvant therapy (NAT) and those who had surgery alone. RESULTS Median age of 319 patients included in the study was 66.3 years (range 23-89) and 140 (57.6%) of them were males. Moreover, NAT was given in 24 (11.8%) patients, and adjuvant therapy in 40 (19.7%) patients. Median follow-up was of 150 months (60-240). In patients who had NAT the mean age was higher (P=0.05), RC were located lower (P=0.009) and higher positive lymph-nodes were found (P=0.003), whereas the number of both local (P=0.4) and distant recurrences (P=0.7) was not significantly lower, compared to the other group. Comparing trends of DFSc a more progressive decrease was shown in patients treated with surgery alone. Even if the differences of DSFc between groups at the end of follow-up were not significant (95% CI: 0.609-2.963, P=0.46), patients who had NAT displayed better survival up to 180 months. CONCLUSIONS Overall, these results showed comparable outcomes between both groups over such a long lasting follow-up. This time frame might be used more extensively for increasing our knowledge of RC biological behaviour as well.

Abdominal paragangliomas: a quantitative prognostic score as predictive factor of the feasibility of the laparoscopic approach

The gold standard treatment for abdominal paraganglioma is the complete surgical excision. The surgical approach may be either open or laparoscopic. The aim of this study is to identify clinical–pathological predictive factors for the failure of the laparoscopic approach in the treatment of abdominal paragangliomas, with the aim of reducing the rate of conversion to the open technique. A retrospective review was conducted on the medical records of patients who underwent laparoscopic surgery for suspected abdominal paraganglioma. To validate parameters which usually act as predictive factors for the laparoscopic outcome in many other interventions, we retrospectively designed a quantitative prognostic score at the beginning of our experience with paragangliomas. The score was based on the clinical and pathological aspects of the disease, as the localization of the tumor in the abdominal cavity, its size, the proximity to major vessels, and the grade of vascularization. At the time of each patient’s discharge, we retrospectively verified the score values. A group of 15 patients underwent laparoscopic surgery for abdominal paraganglioma. In two patients, laparoscopic procedures were converted to laparotomic approaches. Patients reporting a score of ≤3 were all successfully operated laparoscopically, while patients with a score between 5 and 6 were laparotomically converted. There are very few studies assessing the effectiveness of the laparoscopic technique in paragangliomas. The conversion rate of our procedures was still low compared to the mean rate reported in the major studies in the literature. Our scoring system, herewith presented, seeks to avoid time-consuming surgery, which may imply a high risk of intra-operative haemodynamic instability in such patients. The choice of the right approach would minimize blood loss and the consequent surgical stress, improving post-operation outcome.

A long-term evaluation of the quality of life after laparoscopic Nissen-Rossetti anti-reflux surgery

Background: The quality of life (QoL) has been suggested to be the most relevant parameter to assess and monitor the long-term outcome in patients who underwent surgery for gastroesophageal reflux disease (GERD). Patients and Methods: A retrospective evaluation was conducted on patients who underwent Laparoscopic Nissen-Rossetti Fundoplication for GERD between January 1998 and December 2010. To evaluate the long-term results a telephone interview was made using the VISICK score and the GERD-health-related QoL (HRQL) questionnaire at 1, 3, 5 years and at the end of the study. If the questionnaires resulted unsatisfactory, a complete diagnostic revaluation was performed. Results: A total of 168 patients underwent laparoscopic surgery for GERD. When evaluated at the end of the study, the number of unsatisfied patients according to the VISICK score was significantly higher than the one obtained with the GERD-HRQL questionnaire. Conclusions: Many data suggest a possible recurrence of the symptoms after surgery in a long follow-up period. Our data seem to demonstrate a slight but significant trend in symptoms relapse after surgery. Considering the non-specific and specific nature of the two scores, VISICK and GERD HRQL, our result showed a significantly more relevant trend of symptoms relapse only for the non-specific ones. Such QoL scores seem to be important in selecting patients who need to be instrumentally examined. Consequently, our work proves that only a few patients out of the total number of followed up patients, are to be recalled to undergo instrumental examination.