Imaging techniques and combined medical and surgical treatment of perianal Crohn's disease.

Crohn's disease is a chronic inflammatory disease which may involve any segment of the gastrointestinal tract, most frequently the terminal ileum, the large intestine, and the perianal region. The symptoms of perianal Crohn's disease include skin disorders, hemorrhoids, anal ulcers, anorectal stenosis, perianal abscesses and fistulas, rectovaginal fistulas and carcinoma of the perianal region. The perianal manifestations of Crohn's disease cause great discomfort to the patient and are among the most difficult aspects to treat. Management of perianal disease requires a combination of different imaging modalities and a close cooperation between gastroenterologists and dedicated surgeons.

A nationwide audit of the use of radiotherapy for rectal cancer in Italy.

BACKGROUND: There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but its application in Italy has not been investigated. METHODS: We conducted a nationwide survey among members of the Italian Society of Colo-Rectal Surgery (SICCR) on the use of radiation therapy for rectal cancer in the year 2005. Demographic, clinical and pathologic data were retrospectively collected with an online database. Italy was geographically divided into 3 regions: north, center and south which included the islands. Hospitals performing 30 or more surgeries per year were considered high volume. Factors related to radiotherapy delivery were identified with multivariate analysis. RESULTS: Of 108 centers, 44 (41%) responded to the audit. We collected data on 682 rectal cancer patients corresponding to 58% of rectal cancers operated by SICCR members in 2005. Radiotherapy was used in 307/682 (45.0%) patients. Preoperative radiotherapy was used in 236/682 (34.6%), postoperative radiotherapy in 71/682 (10.4%) cases and no radiotherapy in 375 (55.0%) cases. Of the 236 patients who underwent preoperative radiotherapy, only 24 (10.2%) received short-course radiotherapy, while 212 (89.8%) received long-course radiotherapy. Of the 339 stage II-III patients, 159 (47%) did not receive any radiotherapy. Radiotherapy was more frequently used in younger patients (P < 0.0001), in patients undergoing abdominoperineal resection (APR) (P < 0.01) and in the north and center of Italy (P < 0.001). Preoperative radiotherapy was more frequently used in younger patients (P < 0.001), in large volume centers (P < 0.05), in patients undergoing APR (P < 0.005) and in the north-center of Italy (P < 0.05). CONCLUSION: Our study first identified a treatment disparity among different geographic Italian regions. A more systematic audit is needed to confirm these results and plan adequate interventions.

Confocal laser endomicroscopy for the detection of mucosal changes in ileal pouch after restorative proctocolectomy.

BACKGROUND: Pouchitis and dysplasia may affect the reservoir after restorative proctocolectomy. AIMS: To assess the suitability of confocal laser endomicroscopy for the in vivo diagnosis of mucosal changes in ileal pouch for ulcerative colitis and familial adenomatous polyposis. METHODS: Standard endoscopy and endomicroscopy were performed in 18 pouches. Confocal images were scored for the presence of villous atrophy, inflammation, ulceration, colonic metaplasia and dysplasia. Targeted biopsies were taken. Endomicroscopic and histological findings were compared. RESULTS: At standard endoscopy, the signs of pouchitis were recorded in 7/18 (38.9%) patients. At endomicroscopy, pathological features were found in 16/18 (88.9%), villous atrophy in 15/18 (83.3%), inflammation in 13/18 (72.2%), ulceration in 3/18 (16.7%), and colonic metaplasia in 12/18 (67.7%). No dysplasia was observed. At histology, abnormalities were present in 17/18 (94.4%): villous atrophy in 15/18 (83.3%), inflammation in 17/18 (94.4%), ulceration in 6/18 (33.3%), colonic metaplasia in 15/18 (83.3%). Morphological changes of the ileal pouch could be predicted with an accuracy of 94.4% (95% CI: 74.2-99.0). The k-value for intra- and interobserver agreement was 0.93 and 0.78, respectively. CONCLUSIONS: Endomicroscopy may be helpful in the evaluation of morphologic changes in ileal pouch. The small size of the population sample requires further studies for the results to be confirmed.

Gene expression analysis of early and advanced gastric cancers.

Gastric carcinoma is one of the major causes of cancer mortality worldwide. Early detection results in excellent prognosis for patients with early cancer (EGC), whereas the prognosis of advanced cancer (AGC) patients remains poor. It is not clear whether EGC and AGC are molecularly distinct, and whether they represent progressive stages of the same tumor or different entities ab initio. Gene expression profiles of EGC and AGC were determined by Affymetrix technology and quantitative polymerase chain reaction. Representative regulated genes were further analysed by in situ hybridization (ISH) on tissue microarrays. Expression analysis allowed the identification of a signature that differentiates AGC from EGC. In addition, comparison with normal gastric mucosa indicated that the majority of alterations associated with EGC are retained in AGC, and that further expression changes mark the transition from EGC to AGC. Finally, ISH analysis showed that representative genes, differentially expressed in the invasive areas of EGC and AGC, are not differentially expressed in the non-invasive areas of the same tumors. Our data are more directly compatible with a progression model of gastric carcinogenesis, whereby EGC and AGC may represent different molecular stages of the same tumor. Finally, the identification of an AGC-specific signature might help devising novel therapeutic strategies for advanced gastric cancer.

Crohn's disease and Takayasu's arteritis: is this association difficult to find out?

Takayasu's arteritis is rarely reported associated with Crohn's disease in the English world literature. A case of Takayasu's arteritis type V in a young female affected by Crohn's disease is presented and the pathophysiology mechanism, and the clinical and diagnostic aspects are underlined. Surgical strategy is discussed.

Carriage of CARD15 variants and smoking as risk factors for resective surgery in patients with Crohn's ileal disease.

BACKGROUND: It is controversial whether CARD15 variants are truly associated with a more severe form of Crohn's disease. The relative role of CARD15 genotype and smoking in Crohn's disease progression is also debated. AIM: To investigate the association between CARD15 variants and history of resective surgery in patients with Crohn's ileal disease, taking into account smoking as a possible confounding factor. METHODS: We originally assessed CARD15 genotype in 239 north Italian Crohn's disease patients (mean follow-up: 10.1 +/- 8.1 years). We then focused on 193 patients with proven ileal involvement, 70 of whom (36.3%) carried CARD15-mutated alleles (G908R, R702W, L1007fs). RESULTS: Carriage of CARD15 variants was positively associated with family history and ileal-only disease and negatively associated with uncomplicated behaviour at maximal follow-up (P < 0.05). Ileal resection was the only variable independently associated with CARD15 variants at multivariate analysis (OR 3.8; 95% CI 1.6-9.2; P = 0.003). Kaplan-Meier analysis showed that ileal resection was favoured both by CARD15 variant-carriage (P = 0.01) and by smoking (P = 0.05), but smoking did not affect progression to surgery in variant carriers (P = 0.31). Thirteen of 14 (93%) patients being resection-free at 15-year follow-up, had CARD15 wild-type genotype (P = 0.01), whereas only seven (50%) had never smoked (P = 1.0). CONCLUSIONS: In summary, CARD15 variant-associated Crohn's ileitis is virtually committed to stricturing and/or penetrating disease and, eventually, to resective surgery. Smoking accelerates progression to surgery in patients with wild-type CARD15 genotype, but it seems to exert no additional effect in CARD15-variant carriers.

Familial adenomatous polyposis. Surgical treatment: when and how.

Familial adenomatous polyposis is an autosomal dominated inherited disease, caused by the mutation of the tumour suppressor gene adenomatous polyposis coli on chromosome 5. Despite being a rare disorder, accounting for some 1% of colorectal cancers, it represents an interesting model of hereditary disease, because of its intrinsic characteristics, conventionally defined by the presence of more than 100 colorectal polyps, as well as extra-colon manifestations, the attenuated form of the disease, genetic aspects, the inevitable progression to colorectal cancer and hence the correct therapy to treat or prevent the fatal evolution of the disease. Surgical treatment is based above all on two techniques: ileorectal anastomosis, which requires careful surveillance of rectal remnant, and ileal pouch-anal anastomosis, which totally eradicates the disease. The suitability of using these two techniques is discussed in view of new genetic and clinical findings, acquired from personal experience and from the literature.

Difficult hernia repair in the elderly. A particular case.

A particular clinical case personally observed is described. On the basis of this case it is evaluated if it can be correct to implant a mesh in potentially contaminated areas, if preperitoneal repair is the best approach in recurrent or difficult hernia repair and if there are specific contraindications in operating elderly patients.

Colorectal cancer and high grade dysplasia complicating ulcerative colitis in Italy. A retrospective co-operative IG-IBD study.

BACKGROUND: Ulcerative colitis is a well-known risk factor for colorectal cancer. AIM: To take a census of the cases of colorectal cancer in ulcerative colitis patients observed in Italy and to evaluate the clinical presentation of neoplastic complication. PATIENTS AND METHODS: Experts from 28 Italian centres specialised in the management of inflammatory bowel disease or malignancies participated to the study. They were invited to send clinical data of patients with ulcerative colitis complicated by colorectal cancer or high-grade dysplasia consecutively observed between 1985 and 2000. One hundred and twelve patients (92 with cancer and 20 with high-grade dysplasia) were collected. Fourteen of them had undergone colectomy and ileo-rectal anastomosis for ulcerative colitis. Data of surgical patients were analysed separately. RESULTS: The mean age at diagnosis of ulcerative colitis and colorectal cancer patients was 39.3 and 53.2 years, respectively, and the mean duration between diagnosis of ulcerative colitis and cancer was 13.9 years (range 0-53). Inflammation was proximal to the splenic flexure in 71 cases (76.3%). One hundred and three colorectal cancers were registered (93 patients with single lesion and five patients with two synchronous cancers), with 76.7% of cancers being located in the left colon. As to the surgical patients, the mean age at diagnosis of ulcerative colitis and cancer was 28.9 and 47.0 years, respectively, and the mean diagnostic interval for ulcerative colitis and cancer was 18.1 years. Only 51 out of 112 patients were in follow-up. An early diagnosis of neoplasia (high grade dysplasia, stage A or B sec. Dukes) occurred in 72.5% of patients who were subjected to endoscopic surveillance and in 48.0% of patients who did not undergo endoscopic surveillance (p=0.02). CONCLUSIONS: These data show an earlier diagnosis of cancer in patients who had undergone endoscopic surveillance. The poor compliance to the follow-up program, however, reduces its effectiveness. Moreover, total colectomy allows an easier follow-up, with only the rectum being controlled. Colectomy with ileo-rectal anastomosis or proctocolectomy with ileo-anal anastomosis, could represent a valid alternative in patients at high risk of cancer who refuse endoscopic surveillance.

[The minimal bowel resection in Crohn's disease: analysis of prognostic factors on the surgical recurrence]. / Le resezioni di minima per Morbo di Crohn: valutazione di alcuni fattori di rischio di recidiva.

OBJECTIVE: To assess the effect of disease pattern and involvement of the margins on early and late results of enteric resections with hand-sewn anastomosis for Crohns disease. BACKGROUND: Bowel sparing is one of the aims of the surgery for CD. When strictureplasties are not possible, "minimal surgery" (the resection just of the grossly involved tract of bowel) is the current choice. METHODS: One hundred and forty-six cases of resections in 128 patients were performed in the years 1991-2001. We investigated if there is a relationship between disease pattern (perforating and non-perforating) or hystologic involvement of the margins and recurrence (reoperation for recurrent preanastomotic disease). Hand-sewn anastomosis were performed almost in all the cases; we compared the results with the main series of stapled and hand-sewn sutures. RESULTS: Nine surgical complications occurred (7%), requiring six relaparotomies and three conservative treatments. Overall rate of recurrence (median follow-up 44 months) is 17%: 9% in patients with non perforating disease and 19% in patients with perforating disease. The rate of recurrence is 6% in the group of patients with involved margins and 23% in the group with non involved margins. CONCLUSIONS: Limited surgery for CD doesn't increase rate of recurrence; the involvement of margins is not a risk factor for early reoperation. Hand-sewn anastomosis seem to be as safe as stapled ones.

Selection criteria and long-term results of surgery in symptomatic rectocele.

BACKGROUND: The aim of this study was to confirm some selection criteria for the transrectal repair of the anterior rectocele and to compare our surgical results with those reported in the literature. METHODS: From January 1992 to December 1999, 30 females (mean age 52.9 years, range 28-70 yrs) affected by anterior rectocele were prospectively evaluated with a standard questionnaire, clinical examination, proctosigmoidoscopy, colonic transit time, dynamic defecography, anal EMG, anal manometry. Then, they were submitted to transrectal repair of rectocele with anterior plication of the rectal muscular wall. Fourteen (46.6%) of them were also submitted to perineal levatorplasty. Patients were followed postoperatively (mean 25.7 months) with the same standard questionnaire, clinical examination, defecography, and manometry. Results were tested by Fisher's Exact text, Wilcoxon's test, and "t"-test. RESULTS: Rectal dyschezia, incomplete evacuation, digital help in defecating, mean stool frequency, and rectal bleeding significantly improved. After 3 months, 30% of patients had no complaints, 40% had only 1-2 episodes/month complaints, 13.3% had evacuation only using laxatives, and 16.6% were unchanged. Defecography showed a significant reduction of the rectocele in 70% of patients after 3 months. Manometric parameters were not significantly modified. Four (28.6%) out of 14 patients submitted to perineal levatorplasty complained of dyspareunia. CONCLUSIONS: Our surgical results were comparable with those reported in the literature, with more than 80% of successful outcome. Preoperative clinical data and defecography were confirmed to be basic parameters in selecting patients for surgery. Colonic transit time, anal EMG, and anorectal manometry demonstrated to be useful to recognize conditions as slow colonic transit time, peripheral denervation, and reduced voluntary contraction that could lead to a less satisfactory outcome after surgery, and might benefit with a postoperative perineal rehabilitation by biofeedback and anal electrostimulations. The perineal levatorplasty is not suitable in young females, due to the risk of dyspareunia.

[Intestinal carcinoma in Crohn's disease. Report of four cases and review of the literature]. / Carcinoma intestinale e moro di Crohn. Presentazione di 4 casi e revisione della Letteratura.

BACKGROUND: Increasing numbers of intestinal carcinomas in patients affected by Crohn's disease have been reported by several authors, even if the strength of this associations (age, longstanding of the disease, its characteristics and distribution) still has to be elucidated. METHODS: From January 1992 to July 2000, 130 patients with Crohn's disease were submitted to surgery. RESULTS: Four patients showed an associated intestinal carcinoma at operation, in 3 cases located in the ileum, and in 1 case in the colon. Patients' mean age was 54 years. Mean duration time of the Crohn's disease was 7 years. One patient died 3 months after surgery for disseminated peritoneal carcinomatosis, whereas 3 patients are still alive with malignancy free at 5, 8, and 11 years after the tumor resection. CONCLUSIONS: These results suggest the difficulty in recognizing patients with Crohn's disease who are at risk for intestinal carcinoma. Longstanding disease, previous intestinal exclusion surgery, enterocutaneous or other types of fistulas should be considered for the development of cancer. Therefore, the prognosis may be good if early diagnosis and treatment are made.

Randomised controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse.

BACKGROUND: This randomized prospective study compared the outcome of circular hemorrhoidectomy according to the Hospital Leopold Bellan (HLB) technique (Paris) with Longo stapled circumferential mucosectomy (LSCM) in two homogeneous groups of patients affected by circular fourth-degree hemorrhoids with external mucosal prolapse. METHODS: From December 1996 to December 1999, 80 consecutive patients with fourth-degree hemorrhoids and external mucosal prolapse were randomly assigned to two groups. Forty patients (group A: 18 men, 22 women, mean age 50.5 years, range 21 to 82) underwent HLB hemorrhoidectomy, and 40 patients (group B: 15 men, 25 women, mean age 51.0 years, range 29 to 92) underwent LSCM. Before surgery, all patients were selected with a standard questionnaire for symptom evaluation, full proctological examination, flexible rectosigmoidoscopy, dynamic defecography, and anorectal manometry. No significant differences among the two groups were found. All patients were controlled with follow-up questionnaire and with clinical examination at 1, 2, 4, 12, and 54 weeks after the operation. A postoperative manometry was performed 3 months after surgery. RESULTS: The length of the operation was significantly lower in group B (25 +/- 3.1 SD versus 50 +/- 5.3 minutes, P <0.001). Mean hospital stay was 3 +/- 0.4 days in group A and 2 +/- 0.5 days in group B (P <0.01). Mean duration of inability to work was 8 +/- 0.9 days in group B and 15 +/- 1.4 days in group A (P <0.001). Postoperative pain was significantly lower in group B (P <0.001). Mean length of follow-up was 20 +/- 8.0 months in group A and 20 +/- 7.8 months in group B. Late complications were similar in the two groups, with 0%, at present, recurrence rate. CONCLUSIONS: Our results confirm that both operations are safe, easy to perform, and effective in the treatment of advanced hemorrhoids with external mucosal prolapse. However, the LSCM seems to be preferable owing to the fewer postoperative complications, easier postoperative management, and shorter time to return to work. A longer follow-up is required to confirm the true efficacy of this surgical method.

Repair of giant hernias using more prosthesis.

Giant incisional hernias with total loss of substance are an ominous pathological condition characterized by massive depletion of muscular and fascial tissue, by complete loss of the anatomical and physiological function of the abdominal wall and by severe respiratory and visceral involvement. Over a 10-year period we operated 270 patients with voluminous incisional hernias, 12 of which had a total loss of substance. There was no intraoperative mortality. One patient died of myocardial infarction on the fifth and one died of intestinal occlusion and peritonitis the 11th postoperative day. Early postoperative complications occurred in only one patient who had skin necrosis with an infection at the polypropylene mesh. This was successfully treated with systemic antibiotic therapy and topical medication of the wound. There was also one minor recurrence over the pubis 1 year after the operation that required a new operation to replace the mesh. No respiratory complications occurred and all patients were normally active. The good results reported in our series encourage us to continue in this direction even though these patients are at high risk.

[Nosocomial infections. State of the art]. / Le infezioni nosocomiali. Stato dell'arte.

Little information exists up till now about the prevalence of nosocomial and community acquired infections in Italian hospitals. Little is known about the effects of thorough cleaning in today's hospitals. This review examines the common microorganisms associated with hospital acquired infections and their ability to survive in the hospital environment. The most frequent site of hospital acquired infections is the urinary tract, followed by surgical wounds and the upper respiratory tract. Analysis of North America and European data shows that the increase in length of stay for infected patients is the most striking of all examined costs. Improving standards of hygiene in hospitals would be a safe method to control hospital-acquired infections and their costs.

Local regulation of postprandial motor responses in ileal pouches.

BACKGROUND: Local mechanisms are involved in the postprandial regulation of ileal tone in healthy subjects, but whether these mechanisms affect the postprandial tonic response of ileal pouches has not yet been investigated. AIMS: To study the effect of a meal on pouch tone and phasic motor activity in patients with gut continuity or ileostomy and, in the latter group, the effect of a pouch perfusion with chyme or saline. PATIENTS: Twenty patients with ileal pouches: 10 with gut continuity and 10 with ileostomy. METHODS: Pouch tone and the frequency of phasic volume events were recorded with a barostat under fasting and postprandial conditions and after perfusion of the isolated pouch with chyme or saline. RESULTS: The meal increased pouch tone and the frequency of phasic volume events in the patients with gut continuity, but not in those with ileostomy. Pouch perfusion with chyme induced a greater increase in pouch tone than saline. CONCLUSIONS: The meal stimulated pouch tone and phasic motor activity. These effects were at least partially related to local pouch stimulation by intraluminal contents.

[Surgical treatment of Crohn's disease. Indication and management in 20 patients]. / Trattamento chirurgico del morbo di Chron. Indicazioni e tattica chirurgica in 20 pazienti.

MATERIALS AND METHODS: Sixty-seven patients with Crohn's disease underwent surgery in our department in the period 1989-1996. In this paper we evaluated only the first 20 patients. Ten were female and 10 male. There was single localization in 13 patients and multiple in 7. Surgery was limited to the macroscopically involved intestinal segment. Reconstruction of the intestinal tract has been carried out with a double layer polyglycolic acid end-to-end manual anastomosis. RESULTS: We had no operative deaths and early morbidity. In the follow-up we observed 2 anastomotic recurrences respectively three and five years after the operation; none of them required surgical treatment. One patient of 20 had a colocutaneous fistula four months after operation because of the relapse of the disease at preanastomotic level. CONCLUSIONS: The results obtained in our limited experience allow us to affirm that, when elective surgery is possible, the most reliable surgical behaviour is a limited resection of the diseased segment. Quality of life improved after surgery in all patients.

[Echographic evaluation of goiter recurrence]. / Valutazione ecografica della recidiva di gozzo.

Ultrasound is mandatory in the follow up of patients surgically treated for benign thyroid diseases. In this study the Authors have examined 87 patients who underwent different surgical treatments for goiter over 40 years. Ultrasound allowed a more accurate study of residual thyroid, particularly evaluating thyroid tissue morphology in symptomatic patients (43.6%) and detecting many recurrences in asymptomatic patients (37.3%). This study also confirms the advantage of a more extensive surgery to reduce recurrences without increasing complications.