Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease.

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Does CD10 expression individuate a GIST subgroup of patients?

AIM: The aim of the study was to evaluate expression of CD10 in a series of gastrointestinal tumors (GIST) and to find its relationship with prognosis, biological and clinical behavior. GISTs represent the most frequent gastrointestinal (GI) mesenchymal tumors. Biological behavior of GIST cannot be easily predicted; for this reason many biomolecular factors are being investigated to predict prognosis. Recently the role of the CD10 as prognostic predictor in the carcinogenesis of the gastrointestinal carcinomas has been accurately studied. To our knowledge, no data regarding the role of CD10 in GISTs have been published to date. METHODS: CD10 expression was searched by immunohistochemistry in 29 histological specimens of proved GIST surgically treated. Patients' characteristics and all pathologic features of tumors were statistically reviewed and compared to CD10 expression. Survival analysis was also calculated respect to CD10 expression and relevant clinical or pathological features. RESULTS: CD10 was expressed in 24.1% of cases. There was no correlation between CD10 positivity and risk category, morphology, size or mitosis. The CD10 expression status did not prove to be statistically related to worse prognosis, advanced disease (metastasis) or recurrence, however it was significantly correlated to the tumor site. CONCLUSION: CD10 expression in our series seems to be associated to a small bowel origin of tumor. CD10 expression alone failed to reveal a statistically significant prognostic value. However survival analysis revealed worse prognosis in stomach tumours with mitotic count >10/50 HPF.

Risk factors and outcomes of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Retrospective study of 75 single center cases.

OBJECTIVE: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical gold standard in patients with ulcerative colitis (UC). Results are generally satisfactory but there is a significant rate of patients who experience postoperative complications. The aims of our study were to identify the pre- and intraoperative risk factors and their correlation with the reported outcomes. PATIENTS AND METHODS: A retrospective study was conducted on the medical records of all consecutive patients undergoing restorative proctocolectomy with IPAA for UC in our center from 2010 to 2021. Pre- and intraoperative factors were examined and correlated with pouchitis, endoscopic pouchitis, pouch failure, anastomotic leak, postoperative complications classified according to Clavien-Dindo score and stoma outlet obstruction. A univariate and multivariate statistical analysis was performed. RESULTS: Out of 75 patients undergoing 3- or 2-stage IPAA surgery, the coexistence of extraintestinal clinical manifestations and preoperative topical rectal stump therapy for active proctitis were significantly associated with the occurrence of pouchitis (OR=4.4, p=0.03 and OR=7.6, p=0.01). Endoscopic pouchitis was found to be related to preoperative topical rectal therapy (OR=10.2, p=0.007), but not to extraintestinal manifestations of disease. Anastomotic leak was found to be significantly related to pouch failure (OR=22.7, p=0.007). Surgical indication for malignancy increased the risk for early complications (Clavien-Dindo >2) (OR=16.0, p=0.04). Young age was associated with the occurrence of outlet stoma obstruction in patients with recent IPAA surgery (OR=0.97, p=0.05). CONCLUSIONS: Based on observed results, an appropriate preoperative patient assessment aimed at detecting specific risk factors is crucial to identify early or prevent worse outcomes in patients undergoing IPAA surgery.

The impact of COVID-19 pandemic on IBD surgery: a single center experience.

OBJECTIVE: The spread of COVID-19 pandemic forced the national healthcare system to reorganize almost all surgical services, in order to maintain an adequate therapeutic offer. At General Surgery department of Fondazione Policlinico Gemelli in Rome, surgical procedures were progressively reduced to provide beds and personnel for COVID-19. The aim of our study was to analyze the effect of one year of COVID-19 pandemic on Inflammatory Bowel Disease (IBD) surgery in a cohort of patients and evaluate post-operative short-term complications. PATIENTS AND METHODS: Our team retrospectively analyzed the records of IBD patients who were referred to an IBD-related resective surgery from January 2020 to December 2020. These patients were compared to a comparable group of IBD patients who were operated from January 2019 to December 2019. RESULTS: A total of 160 patients were included in the study. Median age was 44 (range 15-77). Patients were referred for Ulcerative colitis (23.1%) and Crohn's disease (76.9%). Eighty-three patients underwent surgery from January 2020 to December 2020, which constitutes a 4.6% increase in the number of patients compared to the same period in 2019. Median post-operative hospital stay increased (7 days in 2019 vs. 6 days in 2020). Laparoscopic was the most frequently performed procedure during both periods (49% in 2019 and 59% in 2020). Complication rates, reported as Clavien-Dindo score 3 or 4, slightly decreased in 2020 (6.5 in 2019 vs. 4.8 in 2020). PCR test for detection of COVID-19 infection was conducted in all the patients before the hospitalization. Two patients out of 70 were tested positive for COVID-19 and their surgeries were rescheduled. CONCLUSIONS: There was no significant reduction in IBD resective surgeries at our center in 2020, nor a deterioration of the outcomes. A reduction of other elective surgical procedures had to be carried out and adequate protective measures for both patients and healthcare workers were established.

New perspectives in the prediction of postoperative complications for high-risk ulcerative colitis patients: machine learning preliminary approach.

OBJECTIVE: Patients with acute severe and medical refractory ulcerative colitis have a high risk of postoperative complications after total abdominal colectomy (TAC). The objective of this retrospective study is to use machine learning to analyze and predict short-term outcomes. PATIENTS AND METHODS: 32 patients with ulcerative colitis were treated with total abdominal colectomy between 2011 and 2017. Biographical data, preoperative therapy, blood chemistry, nutritional status, surgical technique, blood transfusion and preoperative length of stay were the features selected for the statistical analyses and were used as input for the machine learning algorithms to predict the rate of complications. RESULTS: Traditional statistical analysis showed an overall postoperative morbidity rate of 34% and a mortality rate of 3%. Preoperative low serum albumin levels (<2.5 g/dL) were related to a higher risk of minor infectious complications with statistical significance (p<0.05). Preoperative length of stay (>4 days), blood transfusions (≥1 unit) and body temperature (≥37.5°C) demonstrated a major impact on infectious morbidity with statistical significance (p<0.05). Patients treated with steroids and rescue therapy presented a higher risk of minor infectious complications (p<0.05). Evaluating only preoperative features, machine learning algorithms were able to predict minor postoperative complications with a high strike rate (84.3%), high sensitivity (87.5%) and high specificity (83.3%) during the testing phase. CONCLUSIONS: Machine learning is demonstrated to be useful in predicting the rate of minor postoperative complications in high-risk ulcerative colitis patients, despite the small sample size. It represents a major step forward in data analysis by implementing a retrospective study from a prospective point of view.

[Pancreatic fistula after left pancreatectomy. Risk factors analysis on 68 patients]. / La fistola pancreatica dopo pancreasectomia sinistra. Analisi dei fattori di rischio su 68 casi.

AIM: The aim of this study was to identify risk factors related to pancreatic fistula after left pancreatectomy, considering the difference between the use of mechanical suture and the manual suture to close the pancreatic stump. METHODS: Sixty-eight patients, undergoing left pancreatectomy, were included in this study during a 10-year period. Eight possible risk factors related to pancreatic fistula were examined, such as demographic data (age and sex), pathology (pancreatic and extrapancreatic), technical characteristics (stump closure, concomitant splenectomy, additional procedures), texture of pancreatic parenchyma, octreotide therapy. RESULTS: Fourty-one patients (60%) underwent left pancreatectomy for primary pancreatic disease and 27 (40%) for extrapancreatic malignancy. Postoperative mortality and morbidity rates were 1.5% and 35%, respectively. Fourteen patients (20%) developed pancreatic fistula: 4 of them were classified as Grade A, 9 as Grade B and only one as Grade C. Three factors have been significantly associated to the incidence of pancreatic fistula: none prophylactic octreotide therapy, spleen preserving and soft pancreatic texture. It's still unclear the influence of pancreatic stump closure (stapler vs hand closure) in the onset of pancreatic fistula. CONCLUSION: In this study the incidence of pancreatic fistula after left pancreatectomy has been 20%. This rate is lower for patients with fibrotic pancreatic tissue, concomitant splenectomy and postoperative prophylactic octreotide therapy.

[Late complication after colon self-expandable metal stent placement: a case report]. / Complicanza tardiva dopo posizionamento colico di stent metallico autoespandibile: caso clinico.

Treatment of acute colorectal malignant obstruction, by using self-expandable metallic stents is useful for both palliative and decompressive therapy before the final surgical treatment. In this case, the patient may be benefit from a period of medical optimization prior to undergoing planned surgical resection by a colorectal surgeon. This is a minimally invasive procedure, relatively safe, which obviates the need for colostomy for evacuation relieving physical and psychological burden and contributing the improvement of quality of life. Furthermore, this method also has the advantage of being cost-effective. The previous experience in the benign biliary stenosis allowed the extension of using the metallic stents also for the treatment of benign colorectal diseases (diverticular occlusion, anastomotic strictures, colonic endometriosis). Complications of colon self-expandable metallic stents placement may occur during the procedure and soon after placement (early complications) or, rarely, late after insertion (late complications). These include bleeding, re-obstruction, pain, tenesmus, stent migration, and perforation. The authors report a case of an 81 year-old woman with inoperable rectal carcinoma with liver metastasis who underwent palliative treatment of self-expanding metallic stent endoscopic placement. One month later, the patient presented with acute abdomen at Accidents and Emergencies Department. The diagnosis was a late rectosigmoid junction perforation by stent placement.

Preoperative chemoradiation with raltitrexed ('Tomudex') for T2/N+ and T3/N+ rectal cancers: a phase I study.

The use of raltitrexed ('Tomudex') as concomitant chemotherapy during preoperative radiotherapy in chemonaïve patients with stage II/III rectal cancer has been examined in this study and its recommended dose in conjunction with radiotherapy investigated. Forty-five Gray (Gy) of radiotherapy (1.8 Gy daily, 5 days per week) was delivered to the posterior pelvis, followed by a 5.4 Gy boost. Single doses of raltitrexed (2.0, 2.5 and 3.0 mg/m(2)) were administered on days 1, 19 and 38. Only 1 of the 15 patients entered experienced a dose limiting toxicity (DLT) (grade 3 leucopenia) at the 3.0 mg/m(2) dose level. The overall response rate was 80% (five complete responses, seven partial responses). These preliminary data suggest that raltitrexed is a well tolerated and effective treatment when combined with preoperative radiotherapy in patients with stage II/III rectal cancer. The recommended dose of raltitrexed for future phase II studies will be 3.0 mg/m(2).

Prognostic significance of cytoplasmic p53 overexpression in colorectal cancer. An immunohistochemical analysis.

p53 overexpression was studied by immunohistochemistry in 96 consecutive colorectal cancer patients, subdividing positive specimens according to two staining patterns: cytoplasmic or nuclear. Forty-seven per cent of the cases were p53 positive, a significant correlation being found with Dukes' stage (P = 0.0036). A prevalence of nuclear staining was observed in Dukes' B and cytoplasmic in Dukes' D stages. After 36 months, 23% of the patients had a recurrence, and 45% were p53 positive, all Dukes' C-D stage with cytoplasmic staining. The Kaplan-Meier curve showed a significant correlation between p53 cytoplasmic staining and disease-free survival period (P = 0.002). With respect to disease-free survival, the Cox proportional hazard regression test, comparing p53 positivity with Dukes' stage, showed the latter to be the most significant variable. In our series of patients, advanced Dukes' stage tumours were localised in the right colon, where a higher percentage of p53 positivity (67% versus 40% of the left side), as well as a higher frequency of cytoplasmic staining was observed. In conclusion, from the data obtained, a strong correlation between p53 cytoplasmic staining and patient prognosis is clearly indicated.

Preoperative parenteral nutrition in the high risk surgical patient.

In order to assess the significance of malnutrition in determining surgical complications and the possibility of their reduction by preoperative nutritional support (PNS), a randomized controlled trial is being performed at our institution. The results relative to 100 patients who underwent major surgery for gastrointestinal disease, are presented here. In the treatment group 49 patients received 30 kcal/kg/day and 200 mg/kg/day of nitrogen for at least 7 days in the immediate preoperative period (nine patients were excluded from this group due to early surgery--seven cases; or refusal to accept PNS--two cases. Data analysis with their inclusion or exclusion showed similar results.) Fifty-one patients constituted the control group. The observed septic complication rate was, respectively, 30 and 35.3% (p:NS). When the analysis was restricted to the patients with abnormal instant nutritional assessment (INA), as defined by Seltzer et al (serum albumin less than 3.5 g/dl and/or total lymphocyte count less than 1500 cells/mm3), a statistically significant difference was observed in the incidence of sepsis between the two subgroups (21% vs 53.3%, p less than 0.05). Analogous results were obtained from the patients who underwent gastrectomy for gastric cancer: 16.7% of septic complications in the malnourished treated patients and 100% in the malnourished control ones (p less than 0.05). The occurrence of serious sepsis (sepsis score greater than or equal to 10, according to the scoring system developed by Elebute and Stoner) in the malnourished subgroups was 5.2% and 26.7%, respectively, (p = 0.09). The postoperative mortality rate was not significantly changed by the PNS (reduction from 3.9% to 2.5%, p:NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin adsorption to three-liter ethylen vinyl acetate bags during 24-hour infusion.

Insulin adsorption to ethylen vinyl acetate, 3-liter bags injected with 10 insulin units, during 24-hr infusion has been studied. Three different infusions systems (A, B, and C) were tested and eight bags for each system were used. An elevated insulin adsorption resulted in each system. The maximal insulin recovery, expressed as percentage of the original theoretical 3333 microIU/ml insulin concentration, was 19.54% (at time 6), 20.93% (at time 4), and 16.95% (at time 22) for system A, B, and C, respectively. "Dismissed insulin amount" after 24-hr infusion was 1590 +/- 279.5 microIU, 1505.8 +/- 430.5 microIU, and 1253.3 +/- 369.8 microIU for system A, B, and C, respectively. Comparison of insulin concentration values at different times revealed significant differences only at time 18 (if compared with times 0,2.4,6,8,12,14,16) ant at time 20 (if compared with time 4,6,8,10) for system A, and at time 4 (if compared with time 12,14,16,18,20,22,24) for system B. We conclude that a constant but low insulin delivery can be achieved using 3-liter EVA systems and a 24-hr infusion.

Primary hyperparathyroidism. Our experience.

We report our experience in the clinical presentation and management of 12 patients with primary hyperparathyroidism, who underwent successful surgery. Comparing our results with those previously reported in the literature, we have attempted to correlate the kind of parathyroid lesion, the magnitude of hypercalcemia and PTH increase, and clinical symptoms. Often these relationships are intriguing; we have tried to classify our patients describing four groups, according to clinical and humoral findings: 1) patients with very mild hypercalcemia and aspecific symptoms; 2) patients with a finding of recurrent hypercalcemia and prevalent renal involvement; 3) patients with severe hypercalcemia, plurisystemic involvement and general decay; 4) patients with medical emergencies. Finally, some considerations on rare histological pictures (hyperfunctioning carcinoma, oxyphil cell adenoma) are reported.

[Coexistence of hyperthyroidism and thyroid carcinoma. Description of a clinical case]. / Coesistenza di ipertiroidismo-carcinoma tiroideo. Segnalazione di un caso clinico.

The association of hyperthyroidism and thyroid carcinoma, especially multicentric forms, is an unusual event. We present the case of a 49-year-old woman with clinical and radiological findings of hyperfunctioning thyroid nodule that showed, after a subtotal thyroidectomy, histologic evidence of multicentric carcinoma in one lobe and adenoma in the other lobe. The interest of this clinical case is in the coexistence of an independent adenoma with a multicentric carcinoma, revealed by radical surgery that was necessary for the occurrence of a multinodular goiter. The incidence of this situation could be underestimated in consequence of the current surgical approach to the single "hot" nodule and suggests we pay attention to these patients for the possible presence of malignancy in functionally-inhibited thyroid tissue.

Systemic perioperative prophylaxis in elective oncological colorectal surgery: cefotetan versus clindamicin plus aztreonam.

A prospective randomized study was performed with 65 patients undergoing elective surgery for colorectal cancer, to evaluate the prophylactic effect of two different parenteral antibiotic regimens. All patients underwent rigorous mechanical cleansing of the bowel (enemas, laxatives), received low-residue diet 3 days pre-operatively, and were given oral metronidazole (250 mg) five times a day for 3 days preoperatively. They were divided into two groups comparable in age, nutritional status and operative procedure. The patients in group A (36) received 2 g i.v. of cefotetan at induction of anaesthesia and two other administrations every 12 h. Patients in group B (29) were given clindamicin (600 mg, i.v.) at induction of anaesthesia plus aztreonam (1 g, i.v.); two other doses of the same combined antibiotics were administered every 8 h. Five patients were excluded from the study because they underwent Miles procedure; two others because they underwent explorative laparotomy only. The overall incidence of post-operative septic complications was 6.9% (4/58). No significant differences were found in terms of the rate of surgical infections: 3.1 in group A (1/32) and 0% in group B. Urinary tract infections (1 case) and respiratory tract infections (2 cases) were observed only in group B: the rate was found to be 11.5% (3/26); two anastomotic leakages were observed in group A (6.25%) and one in group B (3.8%). These data suggest that cefotetan appears to be as effective as clindamicin plus aztreonam in prophylaxis against infection in elective colorectal surgery.

[Mechanical sutures in surgery of cancer of the rectum (a personal contribution)]. / La sutura meccanica nella chirurgia del cancro del retto (contributo personale).

The EEA Stapler is widely employed in the rectal cancer surgery, particularly allowing a more frequent sphincteric preservation after low anterior resection. The authors rather employ the manual suture whenever possible and report their own experience on EEA Stapler employment in the surgical management of rectal cancer located 12 to 6 cm. from the anal verge. They emphasize this technique pointing out the necessity of further investigations which may confirm the possibility of obtaining a curative complete surgical removal as well as by abdomino-perineal resection.

Colorectal cancer. Epidemiology, etiology, pathogenesis and prevention.

Colorectal cancer (CRC) is a neoplasm with a steadily growing incidence in Western countries. Moreover the age of 50 and over is a critical risk factor. The relationship between dietary, environmental factors and CRC has been evaluated. At present, a number of genetic risk factors such as the genetic susceptibility, tumor suppressor genes and oncogenes are thought to play a major role. The correlation of CRC with adenomatous polyps and chronic inflammatory disease, ulcerative colitis in particular, has been evaluated. Prevention of CRC is mainly based on a rational diet and in the adoption of mass screening programmes.