Helicobacter pylori and gastroesophageal reflux disease: a cross sectional study.

UNLABELLED: BACKGROUND\ AIMS: Helicobacter Pylori (H. Pylori) is a key pathogenetic factor in gastritis, peptic ulcer disease, gastric carcinoma and lymphoma but its relationship with gastroesophageal reflux disease (GERD) is controversial. The aim of the study is to estimate the possible association between the presence of H. pylori and GERD. METHODOLOGY: In this retrospective study we examined the endoscopy and pathology reports of all the 638 consecutive patients who had upper gastrointestinal endoscopy and adequate mucosal sampling in 2005 in our department at the University of Padova. Yates corrected chi2 test was used to compare the H. Pylori frequency in the different histological groups. Multinomial logistic regression was used to identify possible predictors of H. Pylori infection. RESULTS: In this selected population 133 patients were affected by H. Pylori infection (20.8%) and 107 were affected by GERD according to Montreal definition. No significant relation between H. Pylori infection and GERD or NERD (non erosive reflux disease) was evidenced. As expected histological gastritis at the examination confirmed to be the strongest predictor of infection with a odds ratio of 39.4 (95% CI 5.4-287.4, p < 0.01). Upper abdominal pain showed to be the only clinical independent predictors for the presence of H. Pylori infection with a odds ratio of 1.5 (95% CI 1.0-2.3, p = 0.04). CONCLUSIONS: Our study showed that in north eastern Italy there is no association between H. Pylori infection and GERD. On the contrary presence of histological gastritis and upper abdominal pain were confirmed to be significant predictors of H. Pylori infection. No endoscopic characteristic is significantly related to the presence of H. Pylori.

Diode laser treatment of Barrett's esophagus: long-term results.

Different ablation techniques have been utilized in the treatment of Barrett's esophagus (BE) to reduce the risk of degeneration. Treatment complications, risk of recurrence, and buried intestinal metaplasia (IM) are all major concerns. The effect of diode laser treatment on BE, studied in a group of patients over a long-term period, is presented here. All patients with histology of IM or low-grade dysplasia (LGD) treated with diode laser therapy for BE and followed for at least 24 months were included in the study. Treatment sessions were carried out every 3 months and bioptic follow-up examinations were done yearly. Patients without antireflux surgery received proton pump inhibitors. A total of 20 patients with IM, four of them with LGD, were treated with 161 laser sessions (in mean eight per patient) without complications. Complete, sustained endoscopic and histologic remission was obtained in 13 patients (11/12 with BE ≤ 3 cm and 2/8 with BE >3 cm, p < 0.01) and a mean of 83 ± 27% of the metaplasic tissue was removed in all the patients. All four cases of LGD healed to squamous tissue. No buried metaplasia, recurrences, or disease progressions were reported after a mean follow-up of 6 years and 2 months. Diode laser ablation is a safe and effective method in most cases of short BE, while it is less effective in the long form, requiring a large number of sessions. Long-term results show that the risk of recurrence and of buried intestinal metaplasia underneath neosquamous epithelium is negligible.

TGF-beta1 and IGF-1 production and recurrence of Crohn's disease after ileo-colonic resection.

BACKGROUND: Recurrence after surgery is a major problem in the treatment of Crohn's disease (CD). Alteration of healing processes may play a role in this phenomenon. Transforming growth factor beta (TGF-beta) and insulin-like growth factor (IGF-1) have pro-fibrogenic properties and are involved in wound-healing mechanisms. The aim of this study was to assess their role in the CD recurrence after ileo-colonic resection. PATIENTS AND METHODS: Twenty patients with CD, who underwent ileo-colonic resection in the period between 1999 and 2005, were enrolled in this study. Tissue samples were obtained from macroscopically diseased and healthy ileum. The TGF-beta1 and IGF-1 mRNAs were quantified by real-time polymerase chain reaction using glyceraldehyde 3-phosphate dehydrogenase as the housekeeping gene. Histological severity of the disease was assessed to quantify the ileal inflammation. Patients' follow-up was investigated. Comparisons and correlations were carried out with nonparametric tests and survival analysis was performed. RESULTS: Histological inflammation was moderately severe in the diseased bowel, while it was absent in healthy segments (P < 0.01). TGF-beta1 production in healthy bowels showed a direct correlation with clinical CD recurrence (tau = 0.43, P = 0.04) and survival analysis showed that patients who expressed high TGF-beta1 mRNA transcripts in healthy intestines had higher cumulative recurrence rates than those who expressed low TGF-beta1 mRNA levels (P = 0.02). CONCLUSION: Our study suggests that the high levels of TGF-beta1 in healthy bowels of patients who undergo ileo-colonic resection for CD are associated with early clinical disease recurrence, while there seems to be no association between IGF-1 and CD recurrence.

Restorative proctocolectomy for inflammatory bowel disease: the Padova prognostic score for colitis in predicting long-term outcome and quality of life.

BACKGROUND: In 10-20% of cases, it is impossible to distinguish between ulcerative colitis and Crohn's colitis, affecting the possibility to predict the long-term outcome after restorative proctocolectomy (RPC). The study aimed to assess the accuracy of a new prognostic score for inflammatory bowel diseases (IBD) colitis [the Padova Prognostic Score for Colitis (PPSC)] in predicting long-term clinical/functional outcome and quality of life after RPC. MATERIALS AND METHODS: The PPSC was created by the integration of histological and clinical information. The accuracy of the PPSC was tested in predicting long-term clinical outcome (i.e. pouch complications/survival) and quality of life of 58 consecutive patients who had undergone RPC in our institute from 1984 to 2004. Clinical outcome was assessed with an ad hoc functional questionnaire and the revision of the hospital and outpatients clinic notes. Quality of life surveys were carried out with the Padova IBD Quality of Life (PIBDQL) and with Cleveland Global Quality of Life (CGQL) scores. RESULTS: The PPSC predicted pouch fistulae (accuracy = 84.5%; sensitivity = 50%; specificity = 90%) and changes in sexual life (accuracy = 71%; sensitivity = 23%; specificity = 87%). The PPSC also predicted the PIBDQL score with an accuracy of 62%, a sensitivity of 28% and a specificity of 97%, whilst it predicted the CGQL score with an accuracy of 29%, a sensitivity of 12% and a specificity of 80%. The PPSC failed to predict pouchitis or pouch failure. CONCLUSIONS: The Padova Prognostic Score for Colitis proved effective in predicting pouch fistulae or abscesses, but not pouchitis and pouch failure. The PPSC was accurate in predicting disease-specific quality of life.

Minimally invasive surgery for colorectal cancer: quality of life, body image, cosmesis, and functional results.

BACKGROUND: The aims of this cross-sectional study were to assess the long-term quality of life, the body image, and the cosmetic and functional results in patients who had laparoscopic-assisted for colorectal cancer. METHODS: Forty-two patients were enrolled in this study: 21 consecutive patients who had undergone laparoscopic-assisted colonic resection and 21 patients who had open colonic resection, selected according to stage, gender, age, cancer site, and type of resection. The patients answered four questionnaires about their quality of life, body image, functional, and cosmetic results. Nonparametric tests were used for statistical analysis. RESULTS: Postoperative hospital stay was shorter in patients who had laparoscopic-assisted resection. The cosmetic score was significantly better in the laparoscopic-assisted group than in the open group (p < 0.01). In spite of similar overall body image score, patients who had a laparoscopic-assisted resection reported a significantly better satisfaction with their own body (p = 0.05). Quality-of-life and functional results were similar in both groups. CONCLUSIONS: The cosmetic results and the consequent satisfaction with the body were significantly better after laparoscopic assisted resection compared to equivalent open procedure. These effects seemed to be temporary but they could help patients to accept the burden of surgery.

Endovascular treatment of acute pseudoaneurysm associated to pancreaticoduodenectomy.

The study aim is to confirm feasibility and usefulness of endovascular stent-graft placement for superior mesenteric artery acute bleeding in presence of local sepsis. A superior mesenteric artery resection concomitant to a pancreaticoduodenectomy for carcinoma of the pancreas was followed by a saphenous vein bypass. A pancreatic leak associated to infection developed early in the postoperative course. Three weeks later, a massive haemorrhage due to rupture of an acute pseudoaneurysm was successfully treated with an endoluminal covered stent. This occluded two weeks later without important signs of bowel ischemia. The covered-stent placement allowed obtaining primary hemostasis and bowel perfusion preservation in spite of early occlusion. The patient did well after chemotherapy for one year and presented local recurrence at 16 months. Endovascular treatment of acute haemorrhage in presence of an intra-abdominal sepsis is feasible and useful following pancreatic surgery.

A systematic review on the clinical diagnosis of gastrointestinal stromal tumors.

BACKGROUND: The aim of this work was to assess the prevalence of symptoms of gastrointestinal stromal tumors (GISTs) and the diagnostic yield of clinical procedures for its diagnosis. METHODS: Medical databases were consulted between 1998 and 2006 for potentially relevant publications. All studies dealing with the clinical presentation of GIST and related diagnostic procedures were included. Two researchers worked independently on the study selection, quality assessment, data extraction, and analysis phases of the study. RESULTS: Forty-six observational studies were included with a total of 4,534 patients. Gastrointestinal bleeding was the most common clinical presentation. Twenty studies provided adequate information on the diagnostic yield of various procedures. The pooled diagnostic yield of endoscopy + mucosal biopsy and of intestinal contrast radiography was 33.8% (0-100%) and 35.1% (11-100%), respectively, while that of EUS and that of EUS-FNA was 68.7% (40-100%) and 84.0% (73.8-100%), respectively. Abdominal CT scan and MRI had similar pooled diagnostic yields: 73.6% (34.8-100%), and 91.7% (75-100%), respectively. CONCLUSION: Endoscopy + mucosal biopsy should be reserved to patients with gastrointestinal bleeding. EUS-FNA provides direct visualization of the neoplasm and adequate samples for molecular diagnosis. EUS, abdominal CT and MRI may be considered valid alternatives whenever EUS-FNA is unavailable or a cytological diagnosis is unnecessary.

Restorative proctocolectomy for ulcerative colitis: impact on lipid metabolism and adipose tissue and serum fatty acids.

The aim of this prospective study was to evaluate the changes of the metabolism of circulating and storage lipids in patients with ulcerative colitis after restorative proctocolectomy. Fifteen consecutive patients and 15 sex- and age-matched healthy controls were enrolled. Disease activity, diet, inflammatory parameters, plasma lipoprotein concentrations, and fatty acids (FA) of serum phospholipids and of the subcutaneous adipose tissue were assessed at colectomy and at ileostomy closure. In ulcerative colitis patients, total cholesterol and docosahexaenoic acid were lower than in healthy subjects (p < 0.01 and p < 0.05). The median interval between colectomy and ileostomy closure was 6 (range 2-9) months. During that interval, the inflammatory parameters improved, high-density lipoproteins (HDL) cholesterol increased (p < 0.01), and low-density (LDL) cholesterol decreased (p = 0.01). At ileostomy closure, serum arachidonic acid levels were increased (p = 0.04), whereas serum oleic acid level was decreased (p = 0.02). In this interval, no significant alteration, either in serum n-3 FA precursors or in the FA of subcutaneous adipose tissue, was observed. The increase of serum arachidonic acid after colectomy might suggest a lower utilization for inflammatory process. The reduction of LDL cholesterol is an index of malabsorption probably due to the accelerated transit and to the exclusion of the terminal ileum caused by the covering ileostomy.

Health-related quality of life after ileocolonic resection for Crohn's disease: long-term results.

BACKGROUND: Crohn's disease (CD) is a chronic illness that interferes with the daily life of those affected. The aim of the present study was to evaluate long-term health-related quality of life (HRQL) outcome and its clinical predictors in CD patients who have had ileocolonic resection. METHODS: Ninety-seven CD patients, with a mean follow-up of 47.1 months (95% CI, 40.7-53.5 months) after ileocolonic resection, were interviewed by telephone and responded to the generic Cleveland Global Quality of Life (CGQL) questionnaire, and 63 of them also agreed to come to our outpatient clinic to have a Crohn's Disease Activity Index (CDAI) assessment and blood test and to answer the disease-specific Padova Inflammatory Bowel Diseases Quality of Life (PIBDQL) questionnaire. Control groups also were enrolled. RESULTS: The CGQL scores of the 97 CD patients were similar to those of 69 healthy controls. Only the item on current quality of health was scored significantly lower by patients with CD. In contrast, the PIBDQL item and total scores of the CD patients were all significantly lower than those of the respective healthy controls (P < 0.05). Multivariate analysis showed that the CGQL and PIBDQL scores both had a strong linear relationship with number of daily stools and with CDAI score (P < 0.05). CONCLUSIONS: Despite CD patients who have undergone ileocolonic resection having an apparently normal quality of life with a good energy level, as shown by the CGQL, their long-term HRQL is still affected by a significantly impaired quality of health. In fact, the PIBDQL questionnaire showed significant impairment of bowel and systemic symptom domains with important consequences for emotional and social functions. HRQL seems to be significantly related only to current disease activity.

Quality of life after restorative proctocolectomy for ulcerative colitis: different questionnaires lead to different interpretations.

BACKGROUND: According to some researchers, health-related quality-of-life scores for patients who undergo restorative proctocolectomy (RPC) for ulcerative colitis (UC) are comparable to those of healthy control subjects. Other studies show evidence that patients who undergo RPC experience a health-related quality of life similar to patients with mild UC or UC in remission. HYPOTHESIS: The discrepancy in health-related quality-of-life scores among studies may be due to different health-related quality-of-life analyses. DESIGN: Cross-sectional study. SETTING: Outpatient clinic of a tertiary care center. PATIENTS: In the first phase of the study, we consecutively enrolled 24 patients with UC, 24 patients with Crohn disease, and 24 healthy controls. In the second phase of the study, 40 patients who underwent RPC, 43 patients with UC, and 44 controls were consecutively enrolled. INTERVENTIONS: We administered an Italian version of the Cleveland Global Quality of Life (CGQL) instrument, the Padova Inflammatory Bowel Disease Quality of Life instrument, and the Italian 36-Item Short-Form Health Survey. MAIN OUTCOME MEASURES: We evaluated the construct validity, internal consistency, test-retest reliability, sensitivity to change, and discriminant ability of the Italian CGQL instrument. We compared its discriminative ability with that of the Padova Inflammatory Bowel Disease Quality of Life instrument. RESULTS: The Italian CGQL instrument obtained good construct validity, internal consistency, test-retest reliability, and sensitivity to change. The Italian CGQL score did not distinguish patients who underwent RPC from healthy controls and those with mild UC or UC in remission, while the Padova Inflammatory Bowel Disease Quality of Life instrument reported similar scores for patients who underwent RPC and those with mild UC or UC in remission, and showed a difference vs healthy controls. CONCLUSIONS: We validated an Italian version of the CGQL score. The different results obtained with the CGQL and the Padova Inflammatory Bowel Disease Quality of Life instruments can be attributed to the different discriminative ability of the 2 questionnaires.

Enzymes in feces: useful markers of chronic inflammatory bowel disease.

BACKGROUND: Ulcerative colitis and Crohn's disease are characterized by a chronic intestinal inflammation. Since the precise etiology is still unknown, current therapies are aimed at reducing or eliminating inflammation. METHODS: Endoscopy and histology on biopsy specimens remain the gold standard methods for detecting and quantifying bowel inflammation. These technique are expensive, invasive and not well tolerated by patients since the need of repeated examinations affects their quality of life. Although disease activity scores and laboratory inflammatory markers are widely used they showed unreliable relations with endoscopy and histology. Fecal markers have been investigated in inflammatory bowel disease (IBD) by many authors for diagnostic purposes, to assess disease activity and of risk of complications, to predict relapse or recurrence, and to monitor the effect of therapy. Many inflammatory mediators have been detected in the feces such as leukocytes, cytokines and proteins from neutrophil activation. Some of these, particularly lactoferrin and calprotectin, have been demonstrated to be useful in detecting active inflammatory bowel disease, in predicting recurrence of disease after surgery or monitoring the effects of medical therapy. Calprotectin and lactoferrin are remarkably stable and easily detect in stool using ELISA so they appear to be equally recommendable as inflammation markers in the lower gastrointestinal tract especially in IBD patients. CONCLUSION: Fecal markers are non-invasive, simple, cheap, sensitive and specific parameters and are useful to detect strointestinal inflammation.

Prognosis of gastrointestinal stromal tumors.

BACKGROUND/AIMS: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors (GIMT) of the gut. The aim of this retrospective study is to correlate the histological risk factors with the survival of our patients operated for GIST. METHODOLOGY: In our department, from 1980 to October 2003, 15 patients were operated for GIST. Their mean age was 58 years old and 8 of them were males; 10 (67%) were localized in the stomach and 5 (33%) in the small bowel. In 7 cases liver metastases were present at laparotomy and 4 of them also had peritoneal diffusion. We performed immunohistochemistry for c-Kit, SMA and S100p. Mitotic index (MI) and size neoplasm were the main pathological criteria for malignity. The patients with c-kit (CD117) positive neoplasms were divided according to NIH Consensus Conference risk class, MI, tumor size, localization, SMA or S100p presence, liver metastasis and peritoneal metastasis to compare the different 5-year survival rates. Survival analysis was performed using Kaplan-Meier method and log-rank test and a p < 0.05 was considered as significant. RESULTS: Global survival rate after 5 years was 40% and the mortality was, in all cases, due to GIST. In our experience gender, age, tumor size, localization and S100p positivity did not play any role in predicting the prognosis of GIST. On the contrary high MI and SMA positivity are significantly associated to a lower survival rate (33% vs. 86% and 39% vs. 100% at 5 years, respectively). Finally patients with metastases at laparotomy have a significantly lower 5-year survival rate (hepatic 29% vs. 100%, hepatic and peritoneal 25% us. 78%). CONCLUSIONS: In our experience high MI and in some cases SMA expression can be considered assessed risk factors. On the other hand, criteria of benign behavior did not completely predict the long-term clinical outcome.

Endoscopic dilation of benign esophageal strictures in a surgical unit: a report on 95 cases.

Ninety-five patients were treated by endoscopic dilation without fluoroscopic guidance between 1997 and 2005 for benign esophageal strictures. The etiologies were: anastomotic (38), postfundoplication (13), caustic (14), peptic (11), radiation-induced (10) and others (9). The strictures were classified at every session on a 0 to 4 scale on the basis of the diet and the luminal diameter. Savary-Gillard or Through-the Scope balloon dilators were used depending on the type and the location of the stenosis. A total of 472 dilation sessions were carried out without serious complications. A normal and a semisolid diet were respectively achieved in 75% and 91%. Recurrence of dysphagia was found in 33% and 51% of the patients respectively after 2 months and 1 year. Improvement of dysphagia, the number of sessions, and recurrence were significantly better in the patients with postsurgical stenosis as compared with those affected by caustic, peptic, and radiation-induced strictures.

Isolated hepatocytes versus hepatocyte spheroids: in vitro culture of rat hepatocytes.

The use of hepatocytes that express liver-specific functions to develop an artificial liver is promising. Unfortunately, the loss of specialized liver functions (dedifferentiation) is still a major problem. Different techniques, such as collagen entrapment, spherical multicellular aggregates (spheroids), and coculture of hepatocytes with extracellular matrix, have been used to improve the performance of hepatocytes in culture. The aim of this study was to compare two different models of hepatocyte isolation in culture: isolated hepatocytes (G1) and hepatocyte spheroids (60% hepatocytes, 40% nonparenchymal cells, and extracellular matrix) (G2). To test functional activity of hepatocytes, both synthetic and metabolic, production of albumin and benzodiazepine transformation into metabolites was tested. G2 showed a high albumin secretion, while a decrease after 15 days of culture in G1 was noted. Diazepam metabolites were higher in G2 than in G1 in all samples, but had statistical significance at days 14 and 21 (p < 0.01). The glycogen content, after 30 days of culture, was very low in G1 (14.2 +/- 4.4%), while in G2 it was 72.1 +/- 2.6% (p < 0.01). Our study confirms the effectiveness of a culture technique with extracellular matrix and nonparenchymal cells. Maintenance of a prolonged functional activity has been related to restoration of cell polarity and close cell-to-cell contact. We showed that isolated hepatocytes maintain their functional activity for a period significantly reduced, when compared to the hepatocyte spheroids. We confirmed the role of extracellular matrix as a crucial component to promote hepatocyte homeostasis, and the close link between cellular architecture and tissue-specific functions.

Persistence of high CD40 and CD40L expression after restorative proctocolectomy for ulcerative colitis.

AIM: To focus on the role of CD40 and CD40L in their pathogenesis. METHODS: We analyzed by immunohistochemistry the CD40 and CD40L expression in the pouch mucosa of 28 patients who had undergone RPC for UC, in the terminal ileum of 6 patients with UC and 11 healthy subjects. We also examined by flow cytometry the expression of CD40 by B lymphocytes and monocytes in the peripheral blood of 20 pouch patients, 15 UC patients and 11 healthy controls. RESULTS: Ileal pouch mucosa leukocytes presented a significantly higher expression of CD40 and CD40L as compared to controls. This alteration correlated with pouchitis, but was also present in the healthy pouch and in the terminal ileum of UC patients. CD40 expression of peripheral B lymphocytes was significantly higher in patients with UC and pouch, respect to controls. Increased CD40 levels in blood B cells of pouch patients correlated with the presence of spondyloarthropathy, but not with pouchitis, or inflammatory indices. CONCLUSION: High CD40 expression in the ileal pouch mucosa could be implied in the pathogenesis of pouchitis following proctocolectomy for UC, whereas its increased levels on peripheral blood B lymphocytes are associated with the presence of extraintestinal manifestations.

Hepatocyte transplantation in the treatment of acute liver failure: microencapsulated hepatocytes versus hepatocytes attached to an autologous biomatrix.

A liver transplant is considered today to be the only effective therapeutic solution for many otherwise intractable hepatic disorders. However, liver transplantation is beset by shortage of donors. Over the years, many liver support systems have been developed to supply the liver functions, mostly as a bridge to transplantation. Transplantation of isolated hepatocytes (HcTx) instead of whole liver has constituted one of the most appealing possibilities to treat several diseases. We compared two different models of HcTx in a surgical model of acute liver failure in pigs, using microencapsulated hepatocytes (MHcTx) and hepatocytes attached to a porcine biomatrix (PBMHcTx), both transplanted into peritoneum. The collected data were survival, laboratory findings, hemodynamic parameters, light microscopy, histology, MTT, and glycogen content. The group with PBMHcTx has a better outcome than the group with MHcTx (p < 0.05). Histology showed normal morphology of the hepatocytes, high glycogen content, 75% viability, positive MTT, and 95% adhesion of the hepatocytes to the biomatrix. Our biomatrix (PBM) provides cell-to-cell contact and interaction with extracellular matrix, which have been shown to play major roles in hepatocyte survival and physiologic regulation of gene expression, and guarantee a prompt engraftment and an adequate neovascularization. PBMHcTx is a useful method to treat acute liver failure and it indicates a possible liver-direct gene therapy in the treatment of inherited and acquired disorders.

Giant splenic epithelial cyst with elevated serum markers CEA and CA 19-9 levels: an incidental association?

True spleen cysts are uncommon and rarely associated with elevated serum and intracystic tumor markers CA 19-9 and CEA levels. A 19-year-old woman with a left subcostal mass was observed. Echinococcus granulosus serology was negative, and serum tumor markers CA 19-9 and CEA levels were 273 kU/L and 33 ng/mL, respectively. CT-scanning showed a splenic cyst of 18 cm in greatest diameter. The patient underwent total laparoscopic splenectomy and the serum tumor markers progressively decreased and became normal three months after surgery. Splenic cysts derive from an invagination of the splenic capsule in the splenic pulp with a subsequent squamous metaplasia. This last evidence could be confirmed from the variable cellular differentiation lines of the mesothelial squamous cells in the cyst wall. We should not exclude a higher degenerative potential of cystic epithelium that produces de-differentiation proteins. The lowering of the serum levels of the two markers after the cyst removal is witness of the direct relationship between the increment of the serum tumor markers and the presence of the epidermoid cyst.

The role of CD40 in ulcerative colitis: histochemical analysis and clinical correlation.

OBJECTIVES: CD40 co-stimulator seems to be implicated in the loss of tolerance against self-antigens in many autoimmune diseases. The evidence suggests that in the pathogenesis of ulcerative colitis there is an activity state against self-antigens of the gut wall and flora. The aim of this study was to analyse the expression of CD40 in ulcerative colitis, comparing it with Crohn's disease and nonspecific inflammation of the colon and to determine whether there is a relationship between its expression and the activity stage of the disease. METHODS: The expression of CD40 in the colonic samples of 51 patients (30 ulcerative colitis, 9 Crohn's disease and 12 nonspecific inflammation) was analysed by immunohistochemistry. Twenty-four patients with ulcerative colitis were scored according to clinical, endoscopic and histological classification. RESULTS: The mean percentage of CD40+ cells per field in the colonic mucosa was: ulcerative colitis 21 +/- 11%, Crohn's disease 24 +/- 9%, nonspecific inflammation 7 +/- 7%. The ulcerative colitis patients were statistically significantly different compared to the patients with nonspecific inflammation (P < 0.005), even when comparing the patients in remission (P < 0.05). The expression in Crohn's disease was similar to that in ulcerative colitis. The expression of CD40 in ulcerative colitis was directly proportional to the state of activity of the disease according to the clinical (P < 0.02), endoscopic (P < 0.01) and histological (P < 0.02) criteria. CONCLUSIONS: The expression of CD40 in the colonic mucosae of patients with ulcerative colitis is significantly increased and is proportional to the state of activity. The results seem to confirm the hypothesis that a loss of tolerance could be involved in the pathogenesis of this disease.

Role of stapled and hand-sewn anastomoses in recurrence of Crohn's disease.

BACKGROUND/AIMS: Anastomotic recurrence after bowel resection is a major problem in Crohn's disease surgery. The aim of this study is to compare recurrence rate after stapled side-to-side ileo-colonic anastomosis to those after stapled end-to-side or hand-sewn side-to-side anastomosis to distinguish the role of suture technique and anastomotic configuration in the prevention of Crohn's disease recurrence. METHODOLOGY: Eighty-four consecutive patients who had undergone ileo-colonic resection for Crohn's disease were enrolled: 12 of them had stapled side-to-side anastomosis, 36 stapled end-to-side anastomosis and 36 hand-sewn side-to-side anastomosis. We evaluated duration of operation, first bowel movement after operation, postoperative hospital staying, postoperative surgical complications, clinical recurrence and reoperation rate. The statistical analysis was performed using Student's t-test and Fisher exact test. Cumulative recurrence rates were compared using F Cox test and Kaplan-Meier method. RESULTS: No statistically significant difference between the three groups was observed in early postoperative follow up. The stapled side-to-side anastomosis group obtained a better symptom-free survival than the stapled end-to-side group (p=0.04). In the stapled and hand-sewn side-to-side groups reoperation rates were significantly lower than in the stapled end-to-side group (p=0.01 and p=0.05 respectively). CONCLUSIONS: All the three types of anastomosis were demonstrated to be equally safe in early postoperative outcome. A longer follow-up showed a significantly lower incidence of reoperation recurrence in the stapled and hand-sewn side-to-side anastomosis compared to the stapled end-to-side anastomosis group. This result may suggest the configuration of the anastomosis as the key point in the recurrence of anastomotic Crohn's disease.

Risk factors for recurrence of stenosis in Crohn's disease.

A major problem in Crohn's disease (CD) surgery is the high frequency of recurrence after bowel resection. Several factors are thought to influence this phenomenon. CD "phenotype" was identified as one of this factors and obstructing CD seems to be a low risk. We analysed the reoperation rate in patients operated for obstructing CD to identify risk factors for postoperative recurrence avoiding any bias due to an high risk phenotype. We reviewed the records of 120 patients treated for stenosing CD and survival analysis was performed using Kaplan-Meier method. Younger age, acute obstruction, emergency conditions, postoperative complications, small bowel disease, ileo-ileal anastomosis and type of suture resulted to be risk factors for CD recurrence.