Pathogenesis of Fistulating Crohn's Disease: A Review.

Sustained, transmural inflammation of the bowel wall may result in the development of a fistula in Crohn's disease (CD). Fistula formation is a recognized complication and cause of morbidity, occurring in 40% of patients with CD. Despite advanced treatment, one-third of patients experience recurrent fistulae. Development of targeting treatment for fistulae will be dependent on a more in depth understanding of its pathogenesis. Presently, pathogenesis of CD-associated fistulae remains poorly defined, in part due to the lack of accepted in vitro tissue models recapitulating the pathogenic cellular lesions linked to fistulae and limited in vivo models. This review provides a synthesis of the existing knowledge of the histopathological, immune, cellular, genetic, and microbial contributions to the pathogenesis of CD-associated fistulae including the widely accredited contribution of epithelial-to-mesenchymal transition, upregulation of matrix metalloproteinases, and overexpression of invasive molecules, resulting in tissue remodeling and subsequent fistula formation. We conclude by exploring how we might utilize advancing technologies to verify and broaden our current understanding while exploring novel causal pathways to provide further inroads to future therapeutic targets.

Pain, well-being, body image and cosmesis: a comparison of single-port and four-port laparoscopic cholecystectomy.

BACKGROUND: This study aims to compare post-operative pain, well-being, body image and cosmesis in SILS cholecystectomy and four-port laparoscopic cholecystectomy (FPLC). MATERIAL AND METHODS: Forty-two consecutive patients (15 SILS, 27 FPLC) undergoing elective cholecystectomy were included in the study. Peri-operative pain, well-being, body image and cosmesis were evaluated using validated assessment tools. RESULTS: Significantly lower pain scores were reported one week post-operatively in the SILS group (5.6 vs 8.3; p = 0.035). No significant difference was found in analgesic requirements, physical or mental well-being at any time interval. Significantly higher (favourable) body image questionnaire scores were reported in the SILS group at one week (5.4 v 4.5; p < 0.01), two weeks (5.6 vs 4.8; p < 0.01) and one month (5.7 vs 5.0; p < 0.01) post-operatively. CONCLUSION: SILS patients have significantly reduced one-week pain scores and there was no significant difference in well-being between the two groups. Patients who underwent SILS had improved body image and cosmesis. If both techniques are found to be equivalent concerning safety, cost, learning curve and availability, SILS may play a key role in the new era of patient choice.