Preliminary results of the influence of the in vivo use of a lymphatic dye (patent blue v) in the surgical treatment of Crohn's disease.

INTRODUCTION: Recently, the lymphatic vessels has been considered to play a key role in the pathophysiology and, consequently, in the treatment of Crohn's disease (CD). The aim of this study is to show that the evaluation of lymphatic anomaly might be a useful tool in the recognition of the pathological involvement of the intestinal wall in CD. MATERIAL AND METHODS: Fourteen patients with CD who underwent surgical treatment for distal ileum critical stenosis were prospectively evaluated. During surgery, 0.05 to 0.1 mL of Patent Blue V was injected into the subserosal layer of the antimesenteric edge of ileum and colon. The intestinal section was performed just beneath the outflow of the vital dye where it seemed to be normal (≤2 minutes), as a index of healthy intestinal wall. A comparison between the lymphatic alterations and the macroscopic aspects was performed. RESULTS: Out of 14 patients, 13 were electively operated on, whereas 1 was treated in emergency. In 8 patients (57%), laparoscopic approach was chosen in the first instance. One patient needed laparotomic conversion. When comparing the Patent Blue V outflow time with the macroscopic and microscopic evidence of CD, we found an absolute integrity of the intestinal wall with an outflow ≤2 minutes. Mean follow-up was 110 months with a recurrence rate of 14%. CONCLUSION: We can conclude that this method may be of utility to distinguish between normal and diseased intestine in CD. The possible consequences in postsurgical recurrences of this evidence are critical.

Ileal pouch adenomas and carcinomas after restorative proctocolectomy for familial adenomatous polyposis.

BACKGROUND: Restorative proctocolectomy and IPAA has become the treatment of choice in familial adenomatous polyposis. However, several cases of adenomas and carcinomas arising in the ileal pouch were reported. OBJECTIVE: The aim of this study was to evaluate the prevalence and natural history of ileal pouch adenomas and the development of carcinomas in patients with restorative proctocolectomy for familial adenomatous polyposis. DESIGN AND SETTING: We prospectively studied patients who underwent IPAA during the past 20 years at the surgical unit of the University of Florence in Italy. MAIN OUTCOME MEASURES: We investigated the extent of the risk and the factors that are involved in the development of neoplastic changes of the pouch. Furthermore, because it is not entirely clear when and how polyps should be treated, we have revised our modality of treatment for this unusual pathology. PATIENTS: Sixty-nine patients with familial adenomatous polyposis underwent restorative proctocolectomy. In 66 patients, handsewn ileoanal anastomosis with anal canal mucosectomy was performed. After surgery, all patients underwent endoscopic surveillance. RESULTS: After 10 years of follow-up, 1 ileal pouch adenoma was found in 64.9% of restorative proctocolectomy patients, and ileal pouch carcinomas occurred in 2 patients (29 and 59 years old), 3 and 11 years after restorative proctocolectomy. The number of colonic adenomatous polyps influenced the occurrence of pouch adenomas. No patients with <200 colonic adenomas experienced pouch adenomas, but 46% of patients with >1000 colonic polyps had pouch adenomas, and 25% of patients with 200 to 1000 colonic polyps had pouch adenomas at follow-up. No relationship was found between ileal pouch adenomas and pouch shape (J, S, or straight ileoanal anastomosis with multiple myotomies) or the APC mutation. Polyps larger than 5 mm were removed by endoscopy or surgery. CONCLUSIONS: Ileal pouch adenomas were common after restorative proctocolectomy. Patients >50 years of age and patients with >1000 colonic adenomas at the time of colectomy were more prone to ileal pouch adenomas. The development of malignancy in the terminal ileum can present a fast course and does not seem to follow the classic adenoma-carcinoma sequence.

Iterative surgical resection of a recurrent gallbladder carcinoma with long-term survival: report of a case.

Gallbladder carcinoma is a rare, but often lethal disease. Unfortunately, at the time of diagnosis, patients usually have advanced disease (T3-T4) and long-term survival is dismal, ranging from 5 to 12% in the literature. However, this cancer can be successfully treated when the tumour is organ-confined (T1-T2 tumours), as happens in the case of incidental diagnosis at the time of cholecystectomy for gallstones. Here we describe a patient with recurrent gallbladder carcinoma who, treated with iterative surgical resection, is alive and disease-free at 5 years after the final surgical procedure.

Multiplex gene expression profile in inflamed mucosa of patients with Crohn's disease ileal localization: A pilot study.

BACKGROUND: Crohn's disease (CD) is a complex disorder resulting from the interaction of genetic, environmental, and microbial factors. The pathogenic process may potentially affect any segment of the gastrointestinal tract, but a selective location in the terminal ileum was reported in 50% of patients. AIM: To characterize clinical sub-phenotypes (colonic and/or ileal) within the same disease, in order to identify new therapeutic targets. METHODS: 14 consecutive patients undergoing surgery for ileal CD were recruited for this study. Peripheral blood samples from each patient were collected and the main polymorphisms of the gene Card15/Nod2 (R702W, G908R, and 1007fs) were analyzed in each sample. In addition, tissue samples were taken from both the tract affected by CD and from the apparently healthy and disease-free margins (internal controls). We used a multiplex gene assay in specimens obtained from patients with ileal localization of CD to evaluate the simultaneous expression of 24 genes involved in the pathogenesis of the disease. We also processed surgery gut samples with routine light microscopy (LM) and transmission electron microscopy (TEM) techniques to evaluate their structural and ultrastructural features. RESULTS: We found a significant increase of Th17 (IL17A and IL17F, IL 23R and CCR6) and Th1 (IFN-γ) gene expression in inflamed mucosa compared to non-inflamed sites of 14 CD patients. DEFB4 and HAMP, two genes coding for antimicrobial peptides, were also strongly activated in inflamed ileal mucosa, suggesting the overwhelming stimulation of epithelial cells by commensal microbiota. IFN-γ and CCR6 were more expressed in inflamed mucosa of CD patients with ileal localization compared with patients with colonic localization suggesting a more aggressive inflammation process in this site. Morphological analysis of the epithelial lining of Lieberkün crypts disclosed enhanced release activity from goblet mucocytes, whereas the lamina propria contained numerous cells pertaining to various lines. CONCLUSION: We observed that the expression of ileal genes related to Th1 and Th17 activity is strongly activated as well as the expression of genes involved in microbiota regulation.

Comparing outcomes after treatment of rectal cancer over a long-lasting follow-up between patients who were offered surgery alone and surgery with neoadjuvant therapy.

BACKGROUND: To assess outcomes of patients operated on for rectal cancer (RC) by analysing the trends of disease free survival curves (DFSc) after a very long-term follow-up. METHODS: All patients treated with curative intent for RC from 1986 to 2005 were retrospectively analyzed. Other than demographics, disease characteristics and treatment-related factors were considered. The DFSc were compared between patients who had neoadjuvant therapy (NAT) and those who had surgery alone. RESULTS: Median age of 319 patients included in the study was 66.3 years (range 23-89) and 140 (57.6%) of them were males. Moreover, NAT was given in 24 (11.8%) patients, and adjuvant therapy in 40 (19.7%) patients. Median follow-up was of 150 months (60-240). In patients who had NAT the mean age was higher (P=0.05), RC were located lower (P=0.009) and higher positive lymph-nodes were found (P=0.003), whereas the number of both local (P=0.4) and distant recurrences (P=0.7) was not significantly lower, compared to the other group. Comparing trends of DFSc a more progressive decrease was shown in patients treated with surgery alone. Even if the differences of DSFc between groups at the end of follow-up were not significant (95% CI: 0.609-2.963, P=0.46), patients who had NAT displayed better survival up to 180 months. CONCLUSIONS: Overall, these results showed comparable outcomes between both groups over such a long lasting follow-up. This time frame might be used more extensively for increasing our knowledge of RC biological behaviour as well.

Laparoscopic splenectomy 15 years after.

OBJECTIVE: The authors aim to analyze the impact of spleen size on the operative time, the splenic weight, the surgical technique, and the immediate clinical outcome in a series of 116 laparoscopic splenectomies (LS) performed in our department in the last 15 years. This study was also aimed to evaluate the efficacy of hand-assisted LS for splenomegaly. MATERIALS AND METHODS: From July 1995 to January 2010, 116 LS were performed. In all the procedures, the 3- or 4-trocar lateral approach was used. The mean indication for surgery was hematologic diseases. RESULTS: Of the 116 patients (69 females, mean age 41.7), the average weight of the spleens removed was about 450 g. The mean operative time was 100 minutes. Five patients underwent conversion. The mean duration of postoperative hospitalization was 4 days. No long-term complications were reported. Postoperative complications were reported in 3.5% of the cases. CONCLUSIONS: The laparoscopic approach is safe and effective, with a shorter hospital stay and improved morbidity and mortality. LS may be considered as an acceptable indication even in cases of massive splenomegaly, and hand-assisted LS could be considered as a viable alternative to open surgery in patients with massive spleens.

Long-term results of treatment of acute diverticulitis: still lessons to be learned?

The aim of the present study was to evaluate the long-term results in patients treated for diverticular disease (DD), mainly considering indication for surgery, outcome of the treatment modalities and quality of life. All consecutive patients who underwent treatment for diverticular disease since January 2003 to June 2007 were analyzed. Patients were divided into three groups: medical treatment, elective surgery and emergency surgery. The patients responded to the questions of the Cleveland Global Quality of Life (CGQL) questionnaire and to a symptoms questionnaire during a telephone interview. The long-term outcome parameters such as readmission to the hospital, further surgery for DD, current health status, and quality of life were analyzed according to possible predictors. 146 patients (72.2 %) agreed to submit to the telephone interview and were enrolled in the study. The median follow-up was 99 months. Fifty-two patients were managed with medical therapy, 36 patients received elective operations, and 58 patients underwent acute surgery. Twelve patients (12.7 %) complained episodes of persistent abdominal pain after surgical resection, compared with 6 non-surgical patients (11.5 %). No possible predictors of recurrence, reoperation or readmission were found. The CGQL total scores were found to be similar in the three groups. DD affected bowel function and quality of life of patients in the long-term follow-up regardless of the type of therapy adopted. No long-term advantages of colonic resection were found which should be considered only in patients presenting complicated DD.