Corneal involvement in Crohn's disease: an in vivo confocal microscopy study.

PURPOSE: To evaluate the corneal changes of patients with Crohn's disease (CD) using confocal microscopy and to investigate the association among confocal parameters and CD activity and CD treatment. METHODS: Thirty consecutive patients (age: 42 ± 12 years; 19 women and 11 men) affected by CD and 30 control eyes (age matched and gender matched) underwent an ophthalmic examination and, in 1 eye chosen at random, confocal microscopy of the central cornea using the cornea module of Heidelberg Retina Tomograph. The following confocal parameters were evaluated: density of basal epithelial cells, epithelial dendritic cells, anterior and posterior stromal keratocytes, and endothelial cells; the subbasal plexus was assessed for number and tortuosity of the nerve fibers. RESULTS: Routine ophthalmic evaluation was normal in the whole population. At confocal microscopy, 40% of patients with CD had hyperreflective dots in the basal epithelium, which were absent in the control group. Activation of keratocytes was found in 86.6% of patients with CD and was absent in the control group. Compared with controls, patients with CD had lower density of dendritic cells (12.2 ± 26.3 vs. 50.3 ± 37.6 cells per square millimeter; P = 0.001). The other confocal parameters were similar in the 2 groups. No correlation between CD activity index and confocal changes was found. CONCLUSION: Confocal microscopy can detect subtle corneal changes in patients with CD, which may be signs of subclinical inflammation.

[The biliointestinal bypass: a thirty-years experience]. / Il bypass bilio-intestinale. Un'esperienza italiana trentennale.

AIM: Aim of our study was the evaluation of Italian experience with bilio-intestinal bypass in the surgical treatment of morbid obesity. MATERIALS AND METHODS: 1030 patients; mean age 36.1 years; preoperative mean weight Kg 136.7; mean preoperative BMI 48.9 kg/m2; mean follow-up 68 years (1-28). 838 patients underwent open and 192 laparoscopic bilio-intestinal bypass. The laparoscopy operation was performed with five lap ports. Section of the jejunum 30 cm from the Treitz was made by linear stapler. The cholecysto-jejunal anastomosis was completed with 45 mm linear stapler. A side-to-side anastomosis between the proximal jejunum and the last 12-18 cm of the ileum was created by firing a 60 mm linear stapler. RESULTS: Weight loss was satisfactory in 93% of operated patients. Comorbidities (arterial hypertension, diabetes, sleep apnea syndrome) solved in majority of the patients. The main late complications were incisional hernia in open technique and oxalic nephrolithiasis. The reversal rate was 2.5%. CONCLUSION: Our experience showed that bilio-intestinal bypass can obtain good results. Using laparoscopic technique it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convalescence and incisional hernia.

Azathioprine and mesalamine for prevention of relapse after conservative surgery for Crohn's disease.

BACKGROUND & AIMS: Because the reoperation rate for Crohn's disease is high after resective surgery, use of conservative surgery has increased. Mesalamine was investigated for the prevention of postoperative relapse, with disappointing results. The role of azathioprine in the postoperative setting is unknown. We aimed to compare the efficacy and safety of azathioprine and mesalamine in the prevention of clinical and surgical relapse in patients who have undergone conservative surgery for Crohn's disease. METHODS: In a prospective, open-label, randomized study, 142 patients received azathioprine (2 mg. kg -1. day -1 ) or mesalamine (3 g/day) for 24 months. Clinical relapse was defined as the presence of symptoms with a Crohn's Disease Activity Index score >200 and surgical relapse as the presence of symptoms refractory to medical treatment or complications requiring surgery. RESULTS: After 24 months, the risk of clinical relapse was comparable in the azathioprine and mesalamine groups, both on intention-to-treat (odds ratio [OR], 2.04; 95% confidence interval [CI], 0.89-4.67) and per-protocol analyses (OR, 1.79; 95% CI, 0.80-3.97). No difference was observed with respect to surgical relapse at 24 months between the 2 groups. In a subgroup analysis, azathioprine was more effective than mesalamine in preventing clinical relapse in patients with previous intestinal resections (OR, 4.83; 95% CI, 1.47-15.8). More patients receiving azathioprine withdrew from treatment due to adverse events than those receiving mesalamine (22% vs. 8%; P = 0.04). CONCLUSIONS: While no difference was observed in the efficacy of azathioprine and mesalamine in preventing clinical and surgical relapses after conservative surgery, azathioprine is more effective in those patients who have undergone previous intestinal resection.

Repeated liver resection for recurrent metastases from colorectal cancer.

BACKGROUND/AIMS: Repeat hepatectomy is the most effective treatment for recurrent colorectal liver metastases. We aim to assess how repeated liver resections increase survival, without unacceptable surgical risk. METHODOLOGY: Between December 1992 and December 1998, among 19 patients, 5 underwent secondary resection of recurrent metastatic disease. Following the primary liver surgery, three patients had systemic chemotherapy with 5-fluorouracil and two locoregional chemotherapy via Port-a-cath in the gastroduodenal artery. We evaluated survival and we compared time of surgery, duration of Pringle maneuver, blood losses and postoperative stay in the hospital between first and second liver surgery. RESULTS: Perioperative mortality at second liver resection was nil; morbidity minor; mean duration of surgery 320 vs. 260 min; Pringle maneuver 35 vs. 25 min; blood losses 1300 vs. 650 mL; postoperative stay 12.6 vs. 11.5 days. Mean total survival from time of colon resection was 50 months. As an interesting secondary finding, we observed prolonged inhibition of liver regeneration following treatment with Methotrexate. CONCLUSIONS: Repeated hepatic resection is a safe procedure for selected patients. Surgical risk is slightly increased, but the risk/benefit ratio is definitely in favor of as many repeated resections as needed, whenever there is a chance of curative surgery.