Behaviour of the bowel wall during the first year after surgery is a strong predictor of symptomatic recurrence of Crohn's disease: a prospective study.

BACKGROUND: Recurrences after surgery for Crohn's disease are frequent and unpredictable. To date, there is little agreement as to which factors increase a patient risk of early recurrence. AIM: To assess whether the post-operative behaviour of diseased bowel walls, as determined by ultrasound, may be a useful predictor of relapse. METHODS: A total of 127 Crohn's disease patients were monitored after surgery by means of bowel ultrasound as well as by clinical and laboratory evaluations for a median follow-up of 41.0 months. Bowel wall thickness of diseased loops measured at ultrasound during follow-up was compared with the presurgery values. Multivariable survival analysis was performed to elucidate predictors of early post-operative recurrence. Receiver operating characteristic curves were also constructed taking into account bowel wall thickness for selecting Crohn's disease patients with high risk of clinical/surgical recurrence. RESULTS: The estimated 5 years survival probability of symptomatic Crohn's disease recurrence were 90% and 33%, respectively for unchanged/worsened bowel wall thickness vs. improved bowel wall thickness at 12 months from surgery. The hazard ratio for unchanged/worsened bowel wall thickness at 12 months was 8.9 (95% CI: 3.4-23.2). Receiver operating characteristic curve identified a bowel wall thickness > 6.0 mm at 12 months from surgery as directly associated with the risk of having a Crohn's disease recurrence (hazard ratio was 6.5, 95% CI: 2.8-15.4). CONCLUSIONS: Systematic ultrasound follow-up of diseased bowel walls after conservative surgery allows the early identification of patients at high risk of clinical/surgical recurrence.

Role of early ultrasound in detecting inflammatory intestinal disorders and identifying their anatomical location within the bowel.

BACKGROUND: Although bowel ultrasound is a widely accepted diagnostic tool in bowel diseases, its value as the primary imaging procedure in patients with symptoms/signs suggestive of inflammatory bowel disorders is still unclear. AIM: To investigate the accuracy of bowel ultrasound compared with barium X-ray studies, computed tomography, endoscopy and bowel surgery in the initial assessment of inflammatory bowel disorders. METHODS: Four hundred and eighty-seven patients hospitalized consecutively for symptoms or signs suggestive of a bowel disorder between December 1999 and March 2002 were initially enrolled in the study. All patients underwent bowel ultrasound as the first imaging procedure within 36 h of admission; radiographic evaluations, endoscopy and/or surgery were then performed as appropriate and the results of these investigations were used as the gold standard. RESULTS: Three hundred and thirty-six patients had pathological findings of the bowel detectable at ultrasound as the final diagnosis. The main organic disorders found were Crohn's disease (56%), ulcerative/indeterminate colitis (30%), bowel tumours (5%), appendicitis/diverticulitis (2%) and other inflammatory conditions (8%). The overall sensitivity and specificity of bowel ultrasound were 85% and 95%, respectively, whereas the positive and negative predictive values were 98% and 75%, respectively. Comparisons of ultrasound with X-ray or endoscopic results by disease localization showed that the diagnostic performance of ultrasound was higher for inflammatory conditions of the ileum and sigmoid/descending colon (sensitivity of 92% and 87%, respectively), whereas abnormalities localized in the rectum, duodenum and proximal jejunum were often missed by ultrasound. CONCLUSIONS: In expert hands, bowel ultrasound is highly predictive of inflammatory disease localized in the ileum or colon, and may well be used as the primary imaging method when Crohn's disease or ulcerative colitis is suspected on a clinical basis.

Long-term results and multivariate analysis of prognostic factors in 138 consecutive patients operated on for Crohn's disease using "bowel-sparing" techniques.

BACKGROUND: Conservative surgery has become accepted as a useful option for the surgical treatment of complicated Crohn's disease (CD). METHODS: One hundred thirty-eight consecutive patients treated with strictureplasty or miniresections for complicated CD have been observed prospectively. The possible influence of a number of variables on the risk of recurrence was investigated using the Cox proportional hazard model, and a time-to-event analysis was made using the Kaplan-Meier function. RESULTS: There was no perioperative mortality; the morbidity rate was 5.7%. A close correlation was found between the risk of recurrence and the time between diagnosis and first surgery. The overall 5-year recurrence rate was 24%, being 36% in the patients requiring surgery within 1 year of diagnosis and 14% in those operated on more than 1 year after diagnosis. CONCLUSIONS: Risk factor analysis highlighted a group of patients at high risk of surgical recurrence. Given that our results are similar to those reported in other series, we consider strictureplasty and miniresections safe and effective procedures for the treatment of complicated CD.

Description of new "bowel-sparing" techniques for long strictures of Crohn's disease.

In the period of January 1993 to December 1995 we operated on 55 patients with various complications of Crohn's disease. In properly selected cases, obstructive complications of Crohn's disease can be treated effectively by strictureplasty. Long strictures, even if a narrow lumen is still present, are commonly managed by resection, as classic strictureplasties cannot be done; also Finney strictureplasty seems inadequate, as it creates a blind loop that favors bacterial overgrowth and fecal stasis. Three original "sparing bowel" surgical approaches are proposed as possible alternative in the treatment of long stricture in Crohn's disease. We perform side-to-side ileoileal plasty whenever we are faced with severe narrowing of a long segment of small bowel (>10 cm); side-to-side ileocolic plasty whenever very severe disease with narrowing of ileocaecal valve is present; and ileocaecal plasty when terminal ileitis involves the very distal end of the small bowel, but sparing or only minimally affecting the ileocaecal valve. The above-mentioned procedures are described in detail and the clinical outcomes related to the first 8-patient series of our institution are presented.

Third segment cholangio-jejunostomy in the treatment of unresectable klatskin tumors.

BACKGROUND/AIMS: Cholangiocarcinoma of the hepatic hilum is a seldom curable lesion when detected and several methods of palliation have been suggested. Bismuth has proposed an intrahepatic cholangiojejunostomy on the third segment of the liver, which in his experience obtains effective biliary drainage with better quality of life compared with other forms of palliation. PATIENTS AND MATERIALS: We have used this technique in nine cases. We evaluate results, mortality and morbidity, in comparison with other authors' reported series. RESULTS: In the early postoperative period one patient died, two patients suffered from immediate postoperative complications, and jaundice resolved completely in six patients. Long term survival was influenced by the underlying disease. CONCLUSION: Our findings support Bismuth preference for this technique of surgical palliation for non resectable tumors of the biliary tract.

Hepatocarcinoma: considerations on surgical treatment in a personal series of 23 patients.

BACKGROUND/AIMS: Surgical treatment of primary liver tumors has undergone significant changes in recent years because of improved surgical and anesthesiological techniques and better pre- and post-operative care. We review our personal series from 1987-1995. METHODOLOGY: Of 31 cases of hepatocellular carcinoma (HCC) observed in the years 1987-1995, 23 underwent curative resective surgery for a total of 24 liver resections: 6 hepatectomies; 10 segmentectomies; 4 atypical subsegmentectomies; 2 extended resections, with excision of neoplastic thrombi within the portal vein; 1 orthotopic liver transplantation in another institution, and 1 limited segmental resection for tumor recurrence. In 7 recent cases, pre-operative transcatheter arterial chemoembolization (TAE) was used. RESULTS: The mean survival of the 13 patients that are known to be deceased is 27 months (range: 7-114 months). Perioperative mortality was nil. Actuarial 5-year survival rate is 27%. Pre-operative TAE was used in 7 patients: 4 out of 7 lesions were significantly reduced at computed tomography (CT) scan control 21 days following TAE, while in 3 the tumor size was unchanged. CONCLUSIONS: Liver surgery, even major resections, has become safe with no perioperative mortality in our series. In our experience, pre-operative TAE has often produced significant reduction of the mass, but its real efficacy is still the subject of debate. TAE and percutaneous ethanol injection (PET) should be evaluated as part of combined multimodality treatment in the therapy of large lesions previously considered inoperable.

[Strain gauges for measuring the tension at the site of sutures. Use of the original instrument with a personal technic]. / Strain gauges nella misurazione della tensione in sede di sutura. Impiego di strumentario originale con tecnica personale.

The Authors have developed an instrumentation suitable for suture line tension measuring during plastic operations for large incisional hernias. A full description is given of the measuring technique and of the original instrumentation, including two steel bars called "fachiri" and an electric measuring system with strain gauges. With the employment of this technique, relaxing incisions of the muscle aponeurosis can be reduced to the minimum. Being the suture line tension one of the most important causes of relapsing, the Authors believe that this technique provides a sure advantage for the long term results of plastic operations.

Monoconjugated bilirubin as a possible factor in cholesterol gallstone pathogenesis.

HPLC determination of bilirubin conjugates in bile demonstrated a subgroup of patients with cholesterol gallstones who have more monoconjugated than diconjugated bilirubin in their gallbladder bile. None of the patients had abnormal liver function tests nor hemolysis. It was shown that this is not due to differences in liver secretion of the conjugates. In these patients, the more insoluble monoconjugated bilirubin might have provided the nucleus for the subsequent crystallization of cholesterol leading to the formation of cholesterol gallstones.

[Surgical treatment of ulcerative rectocolitis: technical aspects of total restorative proctocolitis with S pouch]. / Il trattamento chirurgico della rettocolite ulcerosa: aspetti tecnici della proctocolectomia totale restaurativa con pouch a S.

Restorative proctocolectomy with an ileal-pouch-anal anastomosis seems to be the treatment of choice for ulcerative colitis. The aim of this study was to discuss a number of technical and functional aspects of the procedure that still appear to be controversial such as the shape of the pouch, the mucosectomy and the type of anastomosis. The authors report on their experience with the surgical treatment of ulcerative colitis with an "S" pouch. The technique reported, however, differs from the original method proposed by Parks and Nicholls in 1978 and the reasons for this surgical choice are discussed. A six-year experience (1993-1999) regarding 35 patients undergoing this approach is reported. No perioperative deaths were observed. The early and long-term complication rates were 8.5% and 11.4%, respectively. The average number of daily evacuations was 4. Mucosectomy affords complete resolution of the disease, while the particular shape of the pouch guarantees good functional results.

[Total versus partial pancreatectomy in the surgical treatment of carcinoma of the pancreatic head]. / Pancreasectomia totale vs pancrasectomia parziale nel trattamento chirurgico del carcinoma della testa del pancreas.

This is a review of the recent advances in total pancreatectomy versus regional pancreatectomy for adenocarcinoma of the head of the pancreas. The rationale for total pancreatectomy comes from a tendency for pancreatic cancer to be multicentric, the absence of the pancreatico-enterostomy and the argument that total pancreatectomy is a better cancer procedure (wider lymphadenectomy and soft tissue resection). In spite of these theoretical advantages, any important impact on morbidity, mortality and ultimately on survival has not been realised. We analyse the principal metabolic and functional sequelae of total pancreatectomy, particularly highlighting the importance of glucagone hormone in maintaining correct blood glucose levels. The data suggest, a tendency to use total pancreatectomy in selected patients on the basis of pre- and intraoperative cytodiagnosis to prevent occult neoplasms in the pancreatic remnant.

[Total gastrectomy for gastric neoplasms]. / Riflessioni sulla nostra esperienza nella gastrectomia totale per neoplasia.

In spite of the decreasing incidence of gastric carcinoma, as it is reported in recent reports from the U.S.A., total gastrectomy and its surgical indications results and complications, focus the interest of surgeons. We analize 61 cases of total gastrectomy for carcinoma, treated in the years 1982-1992. Perioperative mortality and long term survival appear highly satisfactory, mainly if one considers that the site and extension of the neoplasms treated would have severely impaired the possibilities of cure or long term survival with surgery of lesser momentum. We believe that nowaday indications for total gastrectomy can be widened in the hope of improving results of gastric cancer surgery with no or little additional risk.

Preoperative characteristics and postoperative behavior of bowel wall on risk of recurrence after conservative surgery in Crohn's disease: a prospective study.

OBJECTIVE: To evaluate in patients with Crohn's disease, using transabdominal ultrasound, the morphologic characteristics of the diseased bowel wall before and after conservative surgery and to assess whether these characteristics and their behavior in the postoperative follow-up are useful and reliable prognostic factors of clinical and surgical recurrence. SUMMARY BACKGROUND DATA: Ultrasound is effective for evaluating the thickness of bowel wall, the most typical and constant finding of Crohn's disease. No data are currently available concerning the behavior of the diseased intestinal wall after conservative surgery and whether the preoperative characteristics of bowel wall or its behavior after conservative surgery may predict recurrence. METHODS: In 85 consecutive patients treated with strictureplasty and miniresections for Crohn's disease, clinical and ultrasonographic evaluations were performed before and 6 months after surgery. Assessed before surgery were the maximum bowel wall thickness, the length of bowel wall thickening, the bowel wall echo pattern (homogeneous, stratified, and mixed), and the postoperative bowel wall behavior, classified as normalized, improved, unchanged, or worsened. RESULTS: A significant correlation was found between a long preoperative bowel wall thickening and surgical recurrence. Bowel wall thickness after surgery was unchanged or worsened in 43.3% of patients; in these patients, there was a high frequency of previous surgery. Patients with unchanged or worsened bowel wall thickness had a higher risk of clinical and surgical recurrence compared with those with normalized or improved bowel wall thickness. CONCLUSION: With the use of abdominal ultrasound, the authors found that the thickening of diseased bowel wall may unexpectedly improve after conservative surgery, and this is associated with a favorable outcome in terms of clinical and surgical recurrence. In addition to its diagnostic usefulness, ultrasound also provides reliable prognostic information concerning clinical and surgical recurrence in patients with Crohn's disease in the postoperative follow-up.

Oral contrast enhanced bowel ultrasonography in the assessment of small intestine Crohn's disease. A prospective comparison with conventional ultrasound, x ray studies, and ileocolonoscopy.

UNLABELLED: BACKGROUND/ AIM: Although ultrasound (US) has proved to be useful in intestinal diseases, barium enteroclysis (BE) remains the gold standard technique for assessing patients with small bowel Crohn's disease (CD). The ingestion of anechoic non-absorbable solutions has been recently proposed in order to distend intestinal loops and improve small bowel visualisation. The authors' aim was to evaluate the accuracy of oral contrast US in finding CD lesions, assessing their extent within the bowel, and detecting luminal complications, compared with BE and ileocolonoscopy. METHODS: 102 consecutive patients with proven CD, having undergone complete x ray and endoscopic evaluation, were enrolled in the study. Each US examination, before and after the ingestion of a polyethylene glycol (PEG) solution (500-800 ml), was performed independently by two sonographers unaware of the results of other diagnostic procedures. The accuracy of conventional and contrast enhanced US in detecting CD lesions and luminal complications, as well as the extent of bowel involvement, were determined. Interobserver agreement between sonographers with both US techniques was also estimated. RESULTS: After oral contrast, satisfactory distension of the intestinal lumen was obtained in all patients, with a mean time to reach the terminal ileum of 31.4 (SD 10.9) minutes. Overall sensitivity of conventional and oral contrast US in detecting CD lesions were 91.4% and 96.1%, respectively. The correlation coefficient between US and x ray extent of ileal disease was r1 = 0.83 (p<0.001) before and r2 = 0.94 (p<0.001) after PEG ingestion; r1 versus r2 p<0.01. Sensitivity in detecting strictures was 74% for conventional US and 89% for contrast US. Overall interobserver agreement for bowel wall thickness and disease location within the small bowel was already good before but significantly improved after PEG ingestion. CONCLUSIONS: Oral contrast bowel US is comparable with BE in defining anatomic location and extension of CD and superior to conventional US in detecting luminal complications, as well as reducing interobserver variability between sonographers. It may be therefore regarded as the first imaging procedure in the diagnostic work up and follow up of small intestine CD.