Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review

BACKGROUND

This systematic umbrella review aims to investigate and provide an analysis of guidelines regarding the treatment of diverticular abscesses.

MATERIAL AND METHODS

A systematic literature search was performed using the Cochrane Overviews of Reviews model and the 'Clinical Practice Guidelines'; at the end of initial search, only 12 guidelines were included in this analysis. The quality of the guidelines was assessed by adopting the "Appraisal of Guidelines for Research and Evaluation II" (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses.

CONCLUSIONS

Currently, different scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only a few guidelines suggest the use of percutaneous drainage for abscesses with a diameter greater than 4 cm. The differences among guidelines are the consequence of the different selection of scientific evidence. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.

The Dilemma of the Level of the Inferior Mesenteric Artery Ligation in the Treatment of Diverticular Disease: A Systematic Review of the Literature

Background and aim: Although sigmoidectomy is a well-standardized procedure for diverticular disease, there are still unclear areas related to the varying morphology and vascular supply of the sigmoid colon. The level of vascular ligation could affect the functional outcomes of patients operated on for diverticular disease. The aim of this review is to primarily evaluate sexual, urinary and defecatory function outcomes, as well as postoperative results, in patients who underwent surgery for diverticular disease, with or without inferior mesenteric artery (IMA) preservation. Materials and methods: The MEDLINE/PubMed, WOS and Scopus databases were interrogated. Comparative studies including patients who underwent sigmoidectomy for diverticular diseases were considered. Bowel function, genitourinary function, anastomotic leak, operation time, conversion to open surgery, anastomotic bleeding, bowel obstruction were the main items of interest. Results: Twelve studies were included in the review, three randomized and nine comparative studies. Bowel and genitourinary function are not differently affected by the level of vascular ligation. The site of ligation of IMA did not influence the rate of functional complications, anastomotic leak and bleeding. Of note, the preservation of IMA is associated with a higher conversion rate and longer operative time. Conclusions: Despite the heterogeneity of patient groups, and although the findings should be interpreted with caution, functional and clinical outcomes after sigmoidectomy for diverticular disease do not seem to be affected by the level of vascular ligation as long as the IMA is ligated far from its origin.

The Management of Acute Colonic Diverticulitis in the COVID-19 Era: A Scoping Review

Background and Objective: During the COVID-19 pandemic, health systems worldwide made major changes to their organization, delaying diagnosis and treatment across a broad spectrum of pathologies. Concerning surgery, there was an evident reduction in all elective and emergency activities, particularly for benign pathologies such as acute diverticulitis, for which we have identified a reduction in emergency room presentation with mild forms and an increase with more severe forms. The aim of our review was to discover new data on emergency presentation for patients with acute diverticulitis during the Covid-19 pandemic and their current management, and to define a better methodology for surgical decision-making. Method: We conducted a scoping review on 25 trials, analyzing five points: reduced hospital access for patients with diverticulitis, the preferred treatment for non-complicated diverticulitis, the role of CT scanning in primary evaluation and percutaneous drainage as a treatment, and changes in surgical decision-making and preferred treatment strategies for complicated diverticulitis. Results: We found a decrease in emergency access for patients with diverticular disease, with an increased incidence of complicated diverticulitis. The preferred treatment was conservative for non-complicated forms and in patients with COVID-related pneumonia, percutaneous drainage for abscess, or with surgery delayed or reserved for diffuse peritonitis or sepsis. Conclusion: During the COVID-19 pandemic we observed an increased number of complicated forms of diverticulitis, while the total number decreased, possibly due to delay in hospital or ambulatory presentation because of the fear of contracting COVID-19. We observed a greater tendency to treat these more severe forms by conservative means or drainage. When surgery was necessary, there was a preference for an open approach or a delayed operation.

The role of damage control surgery in the treatment of perforated colonic diverticulitis: a systematic review and meta-analysis

INTRODUCTION

Damage control surgery (DCS) is the classic approach to manage severe trauma and has recently also been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. The purpose of the present review is to evaluate the outcomes following DCS for Hinchey II-IV complicated acute diverticulitis (CAD).

METHODS

A comprehensive systematic search was undertaken to identify all randomized clinical trials (RCTs) and observational studies, irrespectively of their size, publication status, and language. Adults who have undergone DCS for CAD Hinchey II, III, or IV were included in this review. DCS is compared with the immediate and definitive surgical treatment in the form of HP, colonic resection, and primary anastomosis (RPA) with or without covering stoma or laparoscopic lavage. We searched the following electronic databases: PubMed MEDLINE, Scopus, and ISI Web of Knowledge. The protocol of this systematic review and meta-analysis was published on Prospero (CRD42020144953).

RESULTS

Nine studies with 318 patients, undergoing DCS, were included. The presence of septic shock at the presentation in the emergency department was heterogeneous, and the weighted mean rate of septic shock across the studies was shown to be 35.1% [95% CI 8.4 to 78.6%]. The majority of the patients had Hinchey III (68.3%) disease. The remainder had either Hinchey IV (28.9%) or Hinchey II (2.8%). Phase I is similarly described in most of the studies as lavage, limited resection with closed blind colonic ends. In a few studies, resection and anastomosis (9.1%) or suture of the perforation site (0.9%) were performed in phase I of DCS. In those patients who underwent DCS, the most common method of temporary abdominal closure (TAC) was the negative pressure wound therapy (NPWT) (97.8%). The RPA was performed in 62.1% [95% CI 40.8 to 83.3%] and the 22.7% [95% CI 15.1 to 30.3%]: 12.8% during phase I and 87.2% during phase III. A covering ileostomy was performed in 6.9% [95% CI 1.5 to 12.2%]. In patients with RPA, the overall leak was 7.3% [95% CI 4.3 to 10.4%] and the major anastomotic leaks were 4.7% [95% CI 2.0 to 7.4%]; the rate of postoperative mortality was estimated to be 9.2% [95% CI 6.0 to 12.4%].

CONCLUSIONS

The present meta-analysis revealed an approximately 62.1% weighted rate of achieving GI continuity with the DCS approach to generalized peritonitis in Hinchey III and IV with major leaks of 4.7% and overall mortality of 9.2%. Despite the promising results, we are aware of the limitations related to the significant heterogeneity of inclusion criteria. Importantly, the low rate of reported septic shock may point toward selection bias. Further studies are needed to evaluate the clinical advantages and cost-effectiveness of the DCS approach.

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

Hyperthermic Intraperitoneal Chemotherapy for Primary or Recurrent Adrenocortical Carcinoma. A Single Center Study

BACKGROUND

This study explores the impact of Hypertermic Intra PEritoneal Chemotherapy (HIPEC) on adrenocortical carcinoma (ACC) management through a safety analysis completed by a preliminary evaluation of survival performances.

METHODS

Retrospective chart review of 27 patients submitted to surgical treatment completed by HIPEC for primary (SP, 13 patients) or recurrent (SR, 14 patients, 17 treatments) ACC. Safety was evaluated by means of procedural morbidity and mortality. Survival performances included multiple end points: local/peritoneal disease-free survival (l/pDFS), overall progression-free survival (OPFS), and overall survival (OS).

RESULTS

In the SP group, mortality was nil and morbidity was 46% (major 23%). At a median follow-up of 25 months, the median value for all the different survival measures had not been reached. Mortality was also nil in the SR group. However, morbidity was 77% (major 18%). Median l/pDFS and OPFS were 12 ± 4 and 8 ± 2 months, respectively. At a median follow-up of 30 months, median OS had not been reached.

CONCLUSION

Surgery and HIPEC is an invasive procedure. Its employment in the surgery for primary setting deserves attention as it may affect oncologic outcomes positively. Its value in the management of recurrences seems less appreciable, albeit it may find its place in the multimodal management of a rare disease for which multiple therapeutic options do not yet exist.

Hospital admission for complicated diverticulitis is increasing in Italy, especially in younger patients: a national database study

BACKGROUND

Epidemiological studies show an increasing trend of hospitalization for acute diverticulitis (AD), but data regarding the trend in hospitalization for complicated AD in Italy are scarce. The aim of this study was to analyze the Italian trend in hospitalization for complicated AD, from 2008 to 2015.

METHODS

Using the Italian Hospital Information System, we identified all patients with complicated colonic AD as a discharge diagnosis. Age- and sex-specific rates for AD as well as type of hospital admission (emergency/elective), type of complication (peritonitis, obstruction, bleeding, abscess, fistula, perforation, sepsis) and type of treatment (medical/surgical), were analyzed.

RESULTS

A total of 41,622 patients with a discharge diagnosis of complicated AD were identified. Over the study period the admission rate grew from 8.8 to 11.8 per 100,000 inhabitants. The hospitalization rate was highest for patients ≥ 70 years, but the increase in the admission rate was higher among patients aged ≤ 60 years. There were more males in the group < 60 years and more females in the group ≥ 60 years old. The rate of emergency admissions associated with surgery showed a significant mean annual increase (+ 3.9% per year) in the rate of emergency admissions associated with surgery, whereas elective admissions for surgery remained stable. Peritonitis was the most frequent complication (35.5%). The rate of surgery increased in AD complicated by peritonitis (+ 5.1% per year), abscess (+ 5.8% per year) and decreased for obstruction (- 1.8% per year).

CONCLUSIONS

From 2008 to 2015, we documented an increasing rate of hospitalization for complicated AD, especially for younger patients, with an increase in surgery for peritonitis and abscess. Further studies are needed to clearly assess the risk factors for complications and risk of surgery.

Abnormal gut motility in inflammatory bowel disease: an update

BACKGROUND

There is substantial evidence linking disturbed gastrointestinal motility to inflammation. Thus, it is not surprising that abnormalities of gastrointestinal motility play a role in inflammatory bowel disease (IBD), affecting patient outcomes. We performed a review of the literature to investigate the relationship between abnormal gut motility and IBD.

METHODS

With an extensive literature search, we retrieved the pertinent articles linking disturbed gut motility to IBD in various anatomical districts.

RESULTS

The evidence in the literature suggests that abnormal gastrointestinal motility plays a role in the clinical setting of IBD and may confuse the clinical picture.

CONCLUSIONS

Abnormal gut motility may be important in the clinical setting of IBD. However, additional data obtained with modern techniques (e.g., magnetic resonance imaging) are needed to individuate in a more precise manner gastrointestinal motor dysfunctions, to understand the nature of clinical manifestations and properly tailor the treatment of patients.

Surgical treatment of acute complicated diverticulitis in the elderly

Although the true prevalence is unknown, colonic diverticulosis is one of the most common disease of the digestive tract in Western countries. Based on administrative data of hospitalized patients, the incidence of diverticulitis has been increasing in last decades. In general, elderly patients undergo less frequently an elective colonic resection; but a substantial part of emergency surgeries is performed in elderly patients. In these older patients the choice of any clinical and surgical option is to be correlated not only to the severity of diverticulitis, but also to general status and the co-existing comorbidities. In this regard, it is mandatory that all patients undergo a multidimensional, comprehensive geriatric assessment to correctly identify those who are fit, vulnerable or frail. The analysis of data currently available highlights three relevant elements: type and severity of peritoneal contamination, hemodynamic conditions (stable or unstable), and concomitant comorbidities (fit or frail status). There is no single ideal surgical treatment that can be considered as gold standard for all clinical presentations; the final clinical decision-making should always be based on patient's general health status, severity of peritonitis and of sepsis. In a septic elderly patient who is hemodynamically unstable, treatment should be as prompt as possible independent of the Hinchey's stage, and could include either a Mickulicz stoma or a DCS strategy. In an elderly patient who is fit and hemodynamically stable, the surgical options are similar to those in a younger patient. If a patient is frail but hemodynamically stable, he should be treated with a Hartmann's procedures.

The Trends of Complicated Acute Colonic Diverticulitis-A Systematic Review of the National Administrative Databases

Background and Objectives: The diverticular disease includes a broad spectrum of different "clinical situations" from diverticulosis to acute diverticulitis (AD), with a full spectrum of severity ranging from self-limiting infection to abscess or fistula formation to free perforation. The present work aimed to assess the burden of complicated diverticulitis through a comparative analysis of the hospitalizations based on the national administrative databases. Materials and Methods: A review of the international and national administrative databases concerning admissions for complicated AD was performed. Results: Ten studies met the inclusion criteria and were included in the analysis. No definition of acute complicated diverticulitis was reported in any study. Complicated AD accounted for approximately 42% and 79% of the hospitalizations. The reported rates of abscess varied between 1% and 10% from all admissions for AD and 5-29% of the cases with complicated AD. An increasing temporal trend was found in one study-from 6% to 10%. The rates of diffuse peritonitis ranged from 1.6% to 10.2% of all hospitalizations and 11% and 47% of the complicated cases and were stable in the time. Conclusions: The available data precluded definitive conclusions because of the significant discrepancy between the included studies. The leading cause was the presence of heterogeneity due to coding inaccuracies in all databases, absence of ICD codes to distinguish the different type of complications, and the lack of coding data about some general conditions such as sepsis, shock, malnutrition, steroid therapy, diabetes, pulmonary, and heart failure.

Multicentre international trial of laparoscopic lavage for Hinchey III acute diverticulitis (LLO Study)

BACKGROUND

Laparoscopic lavage was proposed in the 1990s to treat purulent peritonitis in patients with perforated acute diverticulitis. Prospective randomized trials had mixed results. The aim of this study was to determine the success rate of laparoscopic lavage in sepsis control and to identify a group of patients that could potentially benefit from this treatment.

METHODS

This retrospective multicentre international study included consecutive patients from 24 centres who underwent laparoscopic lavage from 2005 to 2015.

RESULTS

A total of 404 patients were included, 231 of whom had Hinchey III acute diverticulitis. Sepsis control was achieved in 172 patients (74·5 per cent), and was associated with lower Mannheim Peritonitis Index score and ASA grade, no evidence of free perforation, absence of extensive adhesiolysis and previous episodes of diverticulitis. The operation was immediately converted to open surgery in 19 patients. Among 212 patients who underwent laparoscopic lavage, the morbidity rate was 33·0 per cent; the reoperation rate was 13·7 per cent and the 30-day mortality rate 1·9 per cent. Twenty-one patients required readmission for early complications, of whom 11 underwent further surgery and one died. Of the 172 patients discharged uneventfully after laparoscopic lavage, a recurrent episode of acute diverticulitis was registered in 46 (26·7 per cent), at a mean of 11 (range 2-108) months. Relapse was associated with younger age, female sex and previous episodes of acute diverticulitis.

CONCLUSION

Laparoscopic lavage showed a high rate of successful sepsis control in selected patients with perforated Hinchey III acute diverticulitis affected by peritonitis, with low rates of operative mortality, reoperation and stoma formation.

Localization of TNF alpha in ileocolonic biopsies of patients with inflammatory bowel disease

BACKGROUND

Although antitumor necrosis factor alfa (TNFα) agents are widely used to treat patients with inflammatory bowel diseases (IBD) - both Crohn's disease (CD) and ulcerative colitis (UC) - there is still some uncertainty in the cell type expressing TNFα in human ileo-colonic segments.

AIMS

We investigated the immunohistochemical (IHC) expression of TNFα in the ileo-colonic segments of patients with both active CD and UC, to establish its anatomic and cellular localization in the inflamed sites. Our aim was to identify patients potentially resistant to anti TNFα agents.

PATIENTS AND METHODS

Ileo-colonic slides of complete histological mapping of patients with CD and UC before any treatment was started were obtained, and serial sections assessed for TNFα expression, together with IHC markers for lymphocytes, macrophages, and plasma cells.

RESULTS

TNFα was expressed in almost all inflamed segments of IBD patients, albeit with different strength, and was present, in addition to lymphocytes and, to a lesser extent, to macrophages, in plasma cells, where it had a strong positivity, as also demonstrated by colocalization of specific IHC staining. The expression of TNFα was mostly focal in CD patients and more diffuse in UC patients, likely due to the different patterns of inflammation (transmural and mucosal) of the two entities.

CONCLUSIONS

In IBD, TNFα is strongly expressed also in plasma cells, and it is easily evidenced by conventional IHC techniques. It remains to be established whether this observation might be useful in future to establish in routine biopsy samples whether patients may be responsive to treatments toward this cytokine.

Trends in hospital admission for acute diverticulitis in Italy from 2008 to 2015

BACKGROUND

Epidemiological studies in Western countries have documented an increase of hospitalizations for acute diverticulitis (AD) but Italian evidence is scarce. The aim of the present study was to analyse the trend in hospitalization for AD, including in-hospital mortality, in Italy from 2008 to 2015.

METHODS

Through the Italian Hospital Information System of the National Health System, we identified diverticulitis of the colon as a discharge diagnosis. Age- and gender-specific rates of hospitalization for AD were assessed.

RESULTS

174,436 hospitalizations were identified with an increasing rate in 2008-2015 from 39 to 48 per 100,000 inhabitants (p < 0.001). The rate of hospitalization was higher for women, but the increasing trend over time was even more pronounced among men (mean increase per year 3.9% and 2.1% among men and women, respectively) (p < 0.001). The increased rate of hospitalization was accounted for by patients less than 70 years old, especially those under 60. In contrast, the hospitalization rate for older patients (age ≥ 70 years) was higher but remained unchanged during the study period. The number of patients with one hospital admissions was significantly higher than the number of patients with at least two hospitalizations (p < 0.001) and both groups showed a significant and comparable increase year by year. The overall in-hospital mortality rate increased from 1.2 to 1.5% (p = 0.017). More specifically, the increase was observed in patients at their first hospitalization [from 1 to 1.4% (mean increase per year of 3%, p = 0.003)]. An increase in mortality was most evident among women (from 1.4 to 1.8% p = 0.025) and in older patients [age 70-79 years from 1.2 to 1.7% (p = 0.034), ≥ 80 years from 2.9 to 4% (p = 0.001)].

CONCLUSIONS

In Italy, between 2008 and 2015, the rate of hospitalization for AD has been constantly increasing due to the hospitalization of younger individuals, especially men. There was a significant increase of in-hospital mortality especially among women, elderly and during the first hospitalization. These findings suggest the need for increased awareness and clinical skills in the management of this common condition.

Molecular Detection of Codon 12 K-RAS Mutations in Circulating DNA from Serum of Colorectal Cancer Patients

Point mutations of the K-RAS gene at codon 12 are found in about 40% of cases with colorectal cancer. The diagnostic implications of the detection of these mutations and their clinical utility are still unclear. The aim of this study was to test both the feasibility of the detection of the mutated K-RAS gene in serum and its potential role in colorectal cancer detection and monitoring.

Codon 12 K-RAS mutations were examined in DNA extracted from the serum of 35 patients with colorectal cancer and were compared with the K-RAS status in the corresponding primary tumor. Molecular detection was performed by the mutant-enriched PCR (ME-PCR) assay, a sensitive method capable of distinguishing a small quantity of mutated DNA in the presence of abundant wild-type DNA. The occurrence of mutations was compared with clinicopathological parameters as well as CEA and CA19.9 serum levels.

We found codon 12 K-RAS mutations in the tissue of 13/35 (37%) patients. Serum mutations were detected in 5/13 (38.5%) patients with mutated K-RAS in the tissue. 26/35 (74%) patients showed an identical K-RAS pattern in tissue and serum. No codon 12 K-RAS alterations were found in serum samples of 22 patients with benign gastrointestinal diseases. Elevated serum CEA levels were detected in 16 patients, four of whom also presented serum RAS mutations.

Our results confirm that K-RAS mutations can be found in circulating DNA extracted from serum samples of patients with colorectal cancer and show that there is a correspondence between serum and tissue K-RAS patterns.

Long-term Outcome after Colorectal Cancer Resection. Patients’ Self-Reported Quality of Life, Sexual Dysfunction and Surgeons’ Awareness of Patients’ needs

Aims and background

Current follow-up care programs focus mainly on detection of tumor recurrence or metachronous cancer. Other aspects that affect the quality of life (QoL) of long-term survivors, such as sexual dysfunction, psychological distress or depressive symptoms, have been poorly investigated. We studied these issues, and also investigated the surgeons’ awareness of their patients’ needs in order to determine how to improve follow-up care programs.

Methods

QoL of 62 colorectal cancer patients was assessed during follow-up using the European Organization for Research and Treatment of Cancer (EORTC) questionnaire QLQ-C30 and the symptom-specific module (QLQ-CR38). Postoperative sexual problems were evaluated with a 6-item questionnaire. Relevant needs to be examined during follow-up were investigated among patients and surgeons, by filling in the same checklist.

Results

During long-term follow-up (range, 14–74 months), rectal cancer patients reported lower QoL than colon cancer patients regarding defecation-related problems (P = 0.0001). Sixty-one percent of colon cancer patients reported no sexual dysfunction, whereas only 24% of individuals with rectal cancer reported no problems (P = 0.007). Patients reporting no sexual problems had significantly better QoL than the others, particularly with respect to physical functioning (P = 0.001), social functioning (P = 0.05), financial problems (P = 0.01) and body image (P = 0.0001). Addressing emotional problems during follow-up was important for 26% of the patients, while this was neglected by surgeons (P = 0.03).

Conclusions

QoL measurement in a clinical setting may help to detect QoL problems that could otherwise go unnoticed in the routine of follow-up care. Specifically, it was useful to detect defecation-related problems, sexual dysfunction and a mismatch in judging the importance of psychological distress between patients and their doctors. Neglecting these issues may cause long-term postoperative dissatisfaction.

Prognostic Value of Circulating KRAS2 Gene Mutations in Colorectal Cancer with Distant Metastases

While tissue KRAS2 mutations have been extensively investigated, the role of circulating mutant KRAS2 gene in patients with colorectal carcinoma remains obscure. The aim of the present study was to explore the prognostic significance of circulating KRAS2 gene mutational status in subjects undergoing primary treatment for colorectal cancer. Codon 12 KRAS2 mutations were examined in DNA samples extracted from the serum of 86 patients with colorectal cancer and were compared with the KRAS2 status of their primary tumors. Tissue and serum KRAS2 status was compared with other clinicopathological variables (including CEA and CA 19-9 levels) and with cancer-related survival. KRAS2 mutations were found in tissue samples of 28 patients (33%); serum KRAS2 mutations were detected in 10 of them (36%). Serum KRAS2 status was significantly associated with Dukes' stage D (p=0.001) and with preoperative CA 19-9 levels (p=0.01).

At multivariate analysis, cancer-related survival was associated with Dukes' stage (p<0.0001), CEA level (p=0.02), and mutant circulating KRAS2 (p=0.01). All 7 stage D patients with serum KRAS2 mutations died of the disease within 24 months of primary treatment; cancer-related survival was significantly better in 9 stage D patients without serum KRAS2 mutations, with 5 patients (56%) alive after 24 months and 1 patient (13%) alive after 44 months. Residual disease after surgery was evident in all 7 stage D patients with mutant circulating KRAS2, and in 5 out of 9 stage D patients without serum mutations.

Serum KRAS2 status may impact substantially on the management of stage D colorectal carcinoma, since it appears to correlate with prognosis in this patient subgroup.

Myenteric plexitis: A frequent feature in patients undergoing surgery for colonic diverticular disease

BACKGROUND

Diverticular disease of the colon is frequent in clinical practice, and a large number of patients each year undergo surgical procedures worldwide for their symptoms. Thus, there is a need for better knowledge of the basic pathophysiologic mechanisms of this disease entity.

OBJECTIVES

Because patients with colonic diverticular disease have been shown to display abnormalities of the enteric nervous system, we assessed the frequency of myenteric plexitis (i.e. the infiltration of myenteric ganglions by inflammatory cells) in patients undergoing surgery for this condition.

METHODS

We analyzed archival resection samples from the proximal resection margins of 165 patients undergoing left hemicolectomy (60 emergency and 105 elective surgeries) for colonic diverticulitis, by histology and immunochemistry.

RESULTS

Overall, plexitis was present in almost 40% of patients. It was subdivided into an eosinophilic (48%) and a lymphocytic (52%) subtype. Plexitis was more frequent in younger patients; and it was more frequent in those undergoing emergency surgery (50%), compared to elective (28%) surgery (p = 0.007). All the severe cases of plexitis displayed the lymphocytic subtype.

CONCLUSIONS

In conclusion, myenteric plexitis is frequent in patients with colonic diverticular disease needing surgery, and it might be implicated in the pathogenesis of the disease.

slanDCs selectively accumulate in carcinoma-draining lymph nodes and marginate metastatic cells

Dendritic cells (DCs) initiate adaptive immune responses to cancer cells by activating naive T lymphocytes. 6-sulfo LacNAc(+) DCs (slanDCs) represent a distinct population of circulating and tissue proinflammatory DCs, whose role in cancer immune surveillance is unknown. Herein, by screening a large set of clinical samples, we demonstrate accumulation of slanDCs in metastatic tumour-draining lymph nodes (M-TDLN) from carcinoma patients. Remarkably, slanDCs are absent at the primary carcinoma site, while their selective nodal recruitment follows the arrival of cancer cells to M-TDLN. slanDCs surround metastatic carcinoma deposits in close proximity to dead cells and efficiently phagocytose tumour cells. In colon carcinoma patients, the contingent of circulating slanDCs remains intact and competent in terms of IL-12p70 and tumour necrosis factor alpha production, induction of T-cell proliferation and migratory capacity to a set of chemokines produced in M-TDLN. We conclude that activated slanDCs represent previously unrecognized players of nodal immune responses to cancer cells.

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.

Radioguided Parathyroidectomy with Portable Mini Gamma-Camera for the Treatment of Primary Hyperparathyroidism

Background. A proper localisation of pathological parathyroid glands is essential for a minimally invasive approach in the surgical treatment of primary hyperparathyroidism (PHP). The recent introduction of portable mini gamma-cameras (pMGCs) enabled intraoperative scintigraphic scanning. The aim of our study is to evaluate the efficacy of this new method and compare it with the preoperative localisation surveys. Methods. 20 patients were studied; they were evaluated preoperatively by neck ultrasound and (99mm)Tc-sestaMIBI-scintigraphy and intraoperatively with the pMGC IP Guardian 2. The results obtained from the three evaluations were compared. Results. The pMGC presented a sensitivity of 95%, a specificity of 98.89%, and a diagnostic accuracy of 98.18%, which were higher than those of preoperative ultrasound (sensitivity 55%; specificity 95%; diagnostic accuracy 87%) and scintigraphy with (99mm)Tc-sestaMIBI (sensitivity 73.68%; specificity 96.05%; diagnostic accuracy 91.58%). Conclusions. The pMGC can be used effectively as an intraoperative method to find the correct location of the pathological parathyroid glands. The pMGC is more reliable than the currently used preoperative and intraoperative localisation techniques.

Italian consensus conference for colonic diverticulosis and diverticular disease

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

The decrease of mineralcorticoid receptor drives angiogenic pathways in colorectal cancer

Angiogenesis plays a crucial role in tumor growth and progression. Low expression of mineralocorticoid receptor (MR) in several malignant tumors correlates with disease recurrence and overall survival. Previous studies have shown that MR expression is decreased in colorectal cancer (CRC). Here we hypothesize that decreased MR expression can contribute to angiogenesis and poor patient survival in colorectal malignancies. In a cohort of CRC patients, we analyzed tumor MR expression, its correlation with tumor microvascular density and its impact on survival. Subsequently, we interrogated the role of MR in angiogenesis in an in vitro model, based on the colon cancer cell line HCT116, ingenierized to re-express a physiologically controlled MR. In CRC, decreased MR expression was associated with increased microvascular density and poor patient survival. In pchMR transfected HCT116, aldosterone or natural serum steroids largely inhibited mRNA expression levels of both VEGFA and its receptor 2/KDR. In CRC, MR activation may significantly decrease angiogenesis by directly inhibiting dysregulated VEGFA and hypoxia-induced VEGFA mRNA expression. In addition, MR activation attenuates the expression of the VEGF receptor 2/KDR, possibly dampening the activation of a VEGFA/KDR dependent signaling pathway important for the survival of tumor cells under hypoxic conditions.

Circulating endothelial progenitor cells, microvascular density and fibrosis in obesity before and after bariatric surgery

It is not known whether, in obesity, the capillary density or the number of circulating endothelial progenitor cells (EPCs) are reduced, or whether fibrosis of small vessels is also present. In addition, possible effects of weight reduction on these parameters have never been evaluated. Therefore, we investigated EPCs and capillary density in 25 patients with severe obesity, all submitted to bariatric surgery, and in 18 normotensive lean subjects and 12 hypertensive lean patients as controls. All patients underwent a biopsy of subcutaneous fat during bariatric surgery. In five patients, a second biopsy was obtained after consistent weight loss, about 1 year later, during a surgical intervention for abdominoplasty. EPCs and capillary density were reduced in obesity, and EPCs were significantly increased after weight reduction. Vascular collagen content was clearly increased in obese patients. No significant difference in vascular collagen was observed between normotensive obese patients and hypertensive obese patients. After pronounced weight reduction, collagen content was nearly normalized. No difference in stress-strain relation was observed among groups or before and after weight loss. In conclusion, our data suggest that microvascular rarefaction occurs in obesity. EPCs were significantly reduced in obese patients. Pronounced weight loss induced by bariatric surgery seems to induce a significant improvement of EPC number, but not of capillary rarefaction. A pronounced fibrosis of subcutaneous small resistance arteries is present in obese patients, regardless of the presence of increased blood pressure values. Consistent weight loss induced by bariatric surgery may induce an almost complete regression of microvascular fibrosis.

Factors affecting the treatment of multiple colorectal adenomas

BACKGROUND

Currently, no guidelines exist for the treatment of patients with multiple colorectal adenomas (MCRAs) (>10 but <100 synchronous nondiminutive polyps of the large bowel). This retrospective study aimed to investigate the clinical and molecular factors related to different treatments for MCRAs.

METHODS

Patients with MCRAs were consecutively enrolled from January 2003 to June 2011. Sequencing of their APC and MutYH genes was performed. The clinical, molecular, and family histories of the patients were collected using the Progeny database. The patient treatments were divided into three groups of increasing clinical weight: endoscopic polypectomy, segmental resection, and total colectomy. A logistic regression analysis of clinicomolecular factors related to different treatment options was performed.

RESULTS

The study comprised 80 patients (32 women, 40%) with a median age of 53 years (range 13-74 years). The median number of polyps was 33 (range 10-90).The cases included 62 diffuse polyposis, 18 segmental polyposis coli and synchronous colorectal carcinomas (CRC; 34 cases, 43%). The pathogenetic mutations were biallelic MutYH (n = 19, 24%) and APC (n = 4, 5%). The mean follow-up period was 74 months (median 43 months, range 1-468 months). Endoscopic polypectomy was performed in 25 cases (31%), segmental resection in 16 cases (20%), and total colectomy in 39 cases (49%). The logistics regression analysis, considering all the patients, showed that the number of polyps, the presence of CRC, and mutation were correlated with more intensive treatment. For the patients without CRC, only the number of polyps was correlated with the severity of the treatment (p > 0.0166). "On the ROC (receiver operating characteristic) curve, 25 was the number of polyps that best discriminated between surgical and endoscopic therapy.

CONCLUSIONS

The majority of patients with MCRAs undergo surgery. For patients without CRC, only the number of polyps, and not the presence of a disease-causing mutation, is correlated with increased heaviness of treatment. Patients with more than 25 polyps are more likely to undergo a surgical resection.

Epidermal growth factor receptor overexpression/amplification in adenocarcinomas arising in the gastrointestinal tract

INTRODUCTION

it has been suggested that EGFR might be valuable to select patients for immunotherapy for various types of cancers.

AIMS

we investigated: a) the gene/proteins alterations in gastrointestinal cancers using immunohistochemistry (IHC) (gene overexpression) and fluorescence in situ hybridisation (FISH) (gene amplification); and b) the associations between EGFR overexpression and amplification and chromosome 7 aneusomy (CEP7) in these cancers.

METHODS

64 tumor specimens were evaluated by IHC and FISH: 17 adenocarcinoma arising in Barrett´s esophagus, 21 stomach cancers, 17 colon cancers, and 9 liver metastasis of colon carcinoma. IHC for EGFR was scored at 4 levels of intensity of membrane staining. EGFR gene in FISH was considered as amplified or not and chromosome 7 (where EGFR is located) as polysomic or disomic. The ratio between EGFR gene and chromosome 7 was performed by FISH and classified the case as gene amplification when the ratio was > 2. Polisomy was identified when the copies of chromosome 7 were > 2 in more than 8% malignant cells.

RESULTS

no difference was found between EGFR gene amplification/protein overexpression according to cancer site. Concerning IHC, most cases were positive for EGFR intensity (84.4%), while only 50% of cases were positive considering a cut-off of 10%. EGFR FISH amplification was found in 4 cases only (6.2%) and FISH CEP7aneusomy in 40.6%. A statistically significant association was found between EGFR protein positivity (IHC) in term of intensity and EGFR gene amplification by FISH (p = 0.003), and between the EGFR protein positivity (IHC) and chromosome 7 aneusomy (FISH) (p = 0.004).

CONCLUSIONS

EGFR amplification assessed by FISH was found in only 4 cases (6.2%) while chromosome 7 aneusomy was identified in 26 (40.6%) cases. IHC proved that EGFR protein overexpression in gastrointestinal cancers is common but FISH assessment showed that EGFR gene amplification is rare. An association was observed between EGFR gene amplification and EGFR protein overexpression in a low number of cases (p = 0.003). A statistically significant association was found between EGFR protein overexpression and chromosome 7 polysomy (p = 0.004).

Morbid obesity in women is associated to a lower prevalence of thyroid nodules

BACKGROUND

Few studies have recently showed functional and morphological changes of the thyroid gland in relation to obesity. To our knowledge, no data are available about the prevalence of thyroid nodules in female obese patients. The aim of this study was to investigate the prevalence of thyroid nodules in morbidly obese women.

METHODS

One hundred eight consecutive female obese patients were selected from those referred to our medical and surgery outpatients providing that following criteria were satisfied: (1) affected by morbid obesity (body mass index (BMI) >40 kg/m(2)); (2) no previous diagnosis of thyroid disease; (3) biochemically proven euthyroid state at the time of recruitment. Ninety-seven control subjects, constituted by normo-weight and/or slightly overweight (BMI ≤ 30 kg/m(2)) women, should satisfy the above criteria 2 and 3. All the subjects were submitted to ultrasound investigation.

RESULTS

The two groups of patients displayed no differences for age and fT4 levels. Obese patients clearly showed a lower prevalence of thyroid nodules [odds ratio 0.294, 95% confidence interval 0.206-0.382]. A single nodule was found in 23% of obese patients as compared to 65% of control subjects (p < 0.0001). No difference for age (year) was found between obese and non-obese subjects with nodules (40.5 ± 8.2 vs. 44.2 ± 8.9, respectively, p = 0.07).

CONCLUSIONS

Our data clearly show a significantly lower prevalence of thyroid nodules in morbidly obese patients. Further studies are needed to confirm and to understand this first observation.

Increase of colonic mast cells in obstructed defecation and their relationship with enteric glia

BACKGROUND

Mast cells are involved in visceral hypersensitivity and motor activity of the gastrointestinal tract. However, there is almost no information concerning mast cells in constipated patients.

AIMS

The purpose of this study was to investigate mast cells distribution in all colonic layers in controls and severely constipated patients with obstructed defecation.

METHODS

Full-thickness specimens from colons of patients undergoing surgery for obstructed defecation due to refractoriness to other therapeutic interventions (n = 11), compared to controls, were obtained and the number of mast cells (evaluated by specific monoclonal antibodies) were counted in the whole viscus and in the various colonic segments (cecum, ascending, transverse, descending, and sigmoid).

RESULTS

Compared to controls, constipated patients had significantly higher numbers of mast cells, both as an overall number and in single colonic segments. This increase was especially evident in the mucosa and submucosa. Mast cells were homogeneously represented in the various segment of the large bowel, in both controls and patients. Degranulated mast cells were found to be close to enteric glial cells and glial filaments.

CONCLUSIONS

Colonic mast cells are increased in obstructed defecation patients. This might represent a vicariating mechanism to the impaired colonic propulsive activity of these patients.

Colonic mast cells in controls and slow transit constipation patients

BACKGROUND

There is recent evidence that mast cells may play important roles in the gut, especially concerning visceral hypersensitivity and motor activity. However, most data are only available for clinical conditions characterised by diarrhoea, where MC have chiefly investigated in the mucosal layer of the colon and there is almost no information concerning constipation.

AIM

To investigate mast cells distribution in all colonic layers in controls and severely constipated patients.

METHODS

Full-thickness specimens from colons of patients undergoing surgery for slow transit constipation (n=29), compared with controls, were obtained and the number of mast cells (evaluated by specific monoclonal antibodies) counted as a whole and in single colonic segments (caecum, ascending, transverse, descending and sigmoid).

RESULTS

Compared with controls, constipated patients revealed significantly higher number of mast cells, both as overall number and in single colonic segments. The distribution of mast cells resulted fairly homogeneous in the various segment of the large bowel, in both controls and patients, and no significant difference in the percentage of degranulated cells was found between groups.

CONCLUSIONS

Colonic mast cells display a homogeneous distribution within the viscus. This cell population is shown to increase in severely constipated patients, which might represent a mechanism trying to compensate for the impaired propulsive activity of these patients.

Effects of Weight Loss on Structural and Functional Alterations of Subcutaneous Small Arteries in Obese Patients

Structural alterations of subcutaneous small resistance arteries, as indicated by an increased media:lumen ratio, are frequently present in hypertensive and/or diabetic patients and may represent the earliest alteration observed. In addition, media:lumen ratios of small arteries have a strong prognostic significance. However, no data are available about the structure of small resistance arteries of obese patients, particularly after weight loss. We have investigated 27 patients with severe obesity. Twelve of them were normotensive, and 15 were hypertensive. All of the obese patients underwent bariatric surgery. We compared results obtained with those observed in 13 normotensive lean controls and in 13 hypertensive lean patients. All of the subjects and patients underwent a biopsy of subcutaneous fat during surgical intervention. In 8 obese patients, a second biopsy was obtained after consistent weight loss, during a surgical intervention for abdominoplasty. Subcutaneous small resistance arteries were dissected and mounted on a wire myograph, and structural parameters were measured. A concentration-response curve to acetylcholine was performed to evaluate endothelial function. Obese patients, independent from the presence of hypertension, show the presence of an increased media:lumen ratio and media cross-sectional area, together with an impaired endothelial-dependent vasodilatation. After surgical correction of obesity and consistent weight loss, a significant improvement of microvascular structure and of some oxidative stress/inflammation markers were observed. In conclusion, our data suggest that the presence of obesity is associated with structural alterations of subcutaneous small resistance arteries, mainly characterized by hypertrophic remodeling. Weight loss may improve microvascular structure.

Comparison of three distinct methods for the detection of circulating tumor cells in colorectal cancer patients

The detection of circulating tumor cells (CTCs) has considerable utility in the clinical management of patients with solid cancers. However, the phenotypic heterogeneity of CTCs and their low numbers in the bloodstream of patients means that no standardized detection method currently exists for these cells. This, together with differences in pre-analytical sample processing, has led to the collection and accumulation of inconsistent data among independent studies. Here, we compare the ability of three methods to detect CTCs in the blood of colorectal cancer patients. Specifically, different aliquots of the same blood sample were screened for the presence of CTCs by a multimarker RT-PCR assay, the standardized CellSearch assay and dHPLC-based gene mutation analysis. In the population tested, none of the blood samples analysed appeared to be positive by all three methods. Of the samples, 75% were positive for the presence of CTCs by the RT-PCR method. Only 20% were positive by the CellSearch assay, while 14.3% of samples displayed gene mutations consistent with the presence of CTCs when the dHPLC method was applied. The samples which were positive for CTCs by the CellSearch assay did not overlap with those that were positive by dHPLC. Interestingly, however, all of these samples were positive when assessed by RT-PCR. Conversely, of the samples that resulted negative by RT-PCR analysis, none appeared to be positive by either of the other methods. These data, therefore, indicate that of the three methods tested, the multimarker RT-PCR assay provides maximal probability of CTC detection. Here, we present the preliminary results of an ongoing clinical study. Future follow-up involving detection of CTCs in the blood of colorectal cancer patients using these three distinct methods will allow us to verify whether either a single method, or a combination of different assays, is necessary to uncover further prognostic significance of circulating tumor cells.

Rectum-sparing surgery may be appropriate for biallelic MutYH-associated polyposis

PURPOSE

The risk of cancer or severe polyposis of the rectal stump after total colectomy for MutYH-associated polyposis is scarcely defined. To evaluate this risk, we describe the findings of endoscopic surveillance of the rectal stump in a series of patients with biallelic MutYH mutations and polyposis.

METHODS

This is a retrospective, observational, multicenter case series derived from 2 familial cancer registries. Biallelic, germ-line MutYH mutations were found in 14 patients with no adenomatous polyposis coli gene mutations. Eleven of them underwent total colectomy with ileorectal anastomosis and yearly proctoscopic surveillance thereafter. Phenotype and histology of rectal polyps were recorded at diagnosis and during follow-up. Development of adenomas and carcinomas during endoscopic surveillance of the rectal stump was observed.

RESULTS

At diagnosis, 6 patients had attenuated polyposis (10-100 adenomas), 5 patients had classical polyposis, 8 patients had colon carcinoma, and no patient had rectal carcinoma. The mean number of rectal polyps at diagnosis was 2.64 ± 2.11 (range, 0-6). No patients had rectal cancer. The most frequent MutYH mutations were Y165C/Y165C and G382D/G382D in 6 and 2 patients, respectively. During surveillance of the rectal stump after surgery (median duration, 5 y; range, 2-23 y), no patient developed rectal cancer. The mean number of adenomas per proctoscopy was 1.23 ± 2.19 (range, 0-10 adenomas per proctoscopy). This study was limited by the small size and retrospective nature of the case series.

CONCLUSION

Total colectomy with ileorectal anastomosis may be appropriate for patients with MutYH-associated polyposis, provided that they have no rectal cancer or severe rectal polyposis at presentation and that they undergo yearly endoscopic surveillance thereafter.

Enteric neuroglial apoptosis in inflammatory bowel diseases

BACKGROUND

Enteric nervous system abnormalities have been described in patients with inflammatory bowel diseases. However, the mechanisms responsible for these abnormalities remain to date largely unknown.

AIMS

We investigated the potential role of apoptotic phenomena in enteric neurons and enteroglial cells in patients with inflammatory bowel diseases.

PATIENTS AND METHODS

Full-thickness surgical specimens of 19 patients undergoing surgery for medically refractory disease (9 from the ileum of patients with Crohn's disease, 10 from the colon of patients with ulcerative colitis) were assessed for the presence of enteric neurons and enteroglial cells and for their apoptosis by two immunohistochemical methods, one also able to distinguish apoptosis from necrosis. The results were compared with those obtained in control specimens.

RESULTS

Concerning Crohn's disease, the ileal segments displayed a significant increase of apoptotic enteric neurons and enteroglial cells in both the submucous and the myenteric plexus compared to controls. In patients with ulcerative colitis, compared to controls, apoptotic phenomena were significantly reduced in enteric neurons, whereas they were increased in the enteroglial cell population (submucous and myenteric plexus).

CONCLUSIONS

In patients with inflammatory bowel disease apoptotic phenomena involve both enteric neurons and enteroglial cells, and may play a role in the abnormalities of the enteric nervous system. The importance of these findings in the pathophysiology of these conditions remains to be determined.

Hereditary multiple exostoses and juvenile colon carcinoma: A case with a common genetic background?

A case of obstructing colon cancer is described in a 31-year-old patient affected by hereditary multiple exostoses. The association of these two rare conditions, which has never been described previously, and their early onset prompt us to discuss the clinical and genetic elements of a potential common pathogenic scenario.

[Extraintestinal manifestations in Crohn's disease: risk factors and influence of intestinal surgery]

BACKGROUND

Extraintestinal manifestations significantly affect the quality of life of patients with Crohn's disease. The aim of the present study is to define the risk factors for extraintestinal manifestations and the relative influence of intestinal surgery.

PATIENTS AND METHODS

In a cohort of 223 patients with Crohn's disease we analyzed the association between demographic/clinico-pathological factors and extraintestinal manifestations. In addition, we evaluated their association with the timing of appearance of the extraintestinal manifestations with respect to the intestinal surgery.

RESULTS

Fifty-seven patients (25.6%) developed 91 extraintestinal manifestations. Demographic and clinico-pathological variables significantly associated with extraintestinal manifestations were: female gender (OR 2.84, 95% CI: 1.37-5.90) and colonic involvement (OR 2.68, 95% CI: 1.06-6.76). In patients not undergoing surgery and in patients with extraintestinal manifestations present only before surgery, the latency period between the onset of Crohn'S disease and extraintestinal manifestations were 3.7 +/-8.2 and 2.1 +/- 6.3 years, respectively. In patients developed extraintestinal manifestations only after surgery, the latency between surgery and extraintestinal manifestations was 12.0 +/-10.0 years. In 5 patients with early onset of extraintestinal manifestations, these did not regress or recur after surgery.

CONCLUSION

Female gender and colonic involvement are confirmed as risk factors for the development of extraintestinal manifestations in Crohn's disease. Surgical treatment of the intestinal disease represents a therapeutic option for patients with extraintestinal manifestations, as it seems to prevent or delay these manifestations in most cases.

Colonic lymphoid follicles and NOD2/CARD15 mutational status in Crohn's disease

Background

Interactions between the colonic lymphoid system and the genetic background in Crohn's disease are unexplored. This study analysed variations of colonic lymphoid follicles (CLFs) according to the nucleotide-binding oligomerization domain 2 (NOD2) and caspase recruitment domain-containing protein 15 (CARD15) gene in patients with Crohn's disease.

Methods

CLFs were characterized by histology and immunohistochemistry in the specimens of 41 patients undergoing colonic resection for Crohn's disease. Variants of the NOD2/CARD15 gene were assessed by denaturing high performance liquid chromatography and confirmed by DNA sequencing.

Results

Eleven patients had a heterozygous variant of the NOD2/CARD15 gene. The uninvolved colon of mutants had significantly lower CLF density (0·9 versus 2·7 follicles per cm2; P &lt; 0·001) and proportion of those with a germinal centre (9 versus 22 per cent; P = 0·040) than in non-mutants. In active disease, CLF density increased similarly in patients with and without the mutation. The proportion of extramucosal CLFs was higher in mutants than in non-mutants (34 versus 22 per cent; P = 0·030). No significant difference between groups was recorded for cellular profile and proliferation.

Conclusion

Patients with Crohn's disease and the NOD2/CARD15 mutation show a remodelling of CLFs in both uninvolved and actively inflamed intestines. These subjects may have a defective immune response by organized lymphoid structures.

APACHE II, POSSUM, and ASA scores and the risk of perioperative complications in patients with colorectal disease

OBJECTIVE

This study was designed to assess the role of the ASA, POSSUM and APACHE II score systems for predicting the complications in patients undergoing surgery for colorectal diseases.

METHODS

We retrospectively analyzed 539 patients undergoing colorectal surgery between January 1996 and December 2006. The accuracy of ASA, POSSUM and APACHE II score systems for predicting perioperative complications has been analysed.

RESULTS

Total postoperative morbidity was 15%, overall perioperative mortality was 1.5%. APACHE II and POSSUM predicted with the same accuracy the perioperative complications (0.65 and 0.68, respectively), while ASA score system revealed a poorer predicting accuracy (0.56). POSSUM predicted death rate more accurately compared to the APACHE II classification (1.6% vs. 10.4%).

CONCLUSIONS

APACHE II and POSSUM score systems may be useful tools helping surgeons to identify patient groups at high risk for complications. The ASA classification resulted less accurate, probably because related to the anesthesiologist's knowledge.

Does extralaryngeal branching have an impact on the rate of postoperative transient or permanent recurrent laryngeal nerve palsy?

BACKGROUND

This prospective study assessed the prevalence of the extralaryngeal branching of the recurrent laryngeal nerve (RLN) and its impact on the incidence of postoperative transient or permanent RLN palsy.

METHODS

Total or hemithyroidectomy was performed in 115 patients, with a total of 195 RLNs displayed. The RLN extralaryngeal branches were routinely identified and preserved. The postoperative course of each patient was evaluated. Outcomes of patients with and without branching RLN were compared.

RESULTS

In all, 36 of 195 (18.5%) nerves showed extralaryngeal branching: 27 cases (25.5%) on the right and 9 on the left side (10.1%; p = 0.0088).Trifurcation of the RLN was identified in two dissections (1%). Bilateral bifurcations were observed in 3 of 80 (3.7%) patients. We reported four (2.1%) unilateral permanent RLN palsies, eight cases of unilateral transient nerve palsy (4.1%), and one bilateral transient RLN injury (0.6%). The comparative analysis of postoperative outcomes between branched and nonbranched RLNs revealed that the anatomical variation was more frequently associated both with unilateral permanent RLN palsy (relative risk, 13.25; 95% confidence interval, 1.42-123.73; p = 0.0204) and unilateral transient RLN palsy (relative risk, 7.36; 95% confidence interval, 1.84-29.4; p = 0.0061). The only case of bilateral transient RLN injury was associated with a nonrecurrent inferior laryngeal nerve.

CONCLUSIONS

Branched RLNs represent a risk factor both for transient and permanent nerve palsy after surgery. Awareness of this anatomical variation and its routine investigation are essential during thyroid surgery to limit its relevant impact on postoperative RLN injury rate.

The changing impact of age on colorectal cancer surgery. A trend analysis

OBJECTIVE

The aim of the study was to evaluate the changing influence of age on the outcomes of colorectal cancer surgery in a retrospective trend analysis.

METHODS

Data on 985 patients undergoing colorectal cancer surgery were collected during 1975-1984 and 1995-2004. Variables and outcomes of patients aged < 65, 65-74, 75-84 and 85+ years were compared with intra- and interdecade analyses. Endpoints of the study were postoperative mortality, 5-year overall and cancer-related survivals.

RESULTS

The rate of elderly patients undergoing colorectal cancer surgery increased significantly from 1975-1984 to 1995-2004. Distribution of American Society of Anesthesiology score and cancer stage remained unchanged over time. The rate of palliative procedures decreased over time, most significantly in the older age groups. In 1995-2004 the palliation rate was similar across all age groups. The rate of emergency surgery also decreased, but it remained higher in older age groups. Operative mortality rate decreased over time across all age groups, but age-related differences were still observed in the 1995-2004 series. Cancer-related survival after curative surgery increased from 58% in 1975-1984 to 64% in 1995-2004 in 75+ years patients, while it increased from 56% to 78% in patients aged 74 years or younger.

CONCLUSIONS

Elderly patients with colorectal cancer benefited substantially from healthcare progress during the last 30 years. The reduction of palliative procedures and the decline in operative mortality document the efficacy of not restricting the access to radical surgery for these patients.

Modifiable risk factors in colorectal surgery: central role of surgeon's volume

BACKGROUND

Our objective was to inform the ongoing debate regarding selective referral of colorectal cancer patients to high-volume surgeons in order to improve outcomes.

PATIENTS AND METHOD

We evaluated data on patients treated by colorectal-dedicated surgeons (first study-group) and non specialized surgeons (second study-group). Particular attention has been paid to patients selection in order to collect two study-groups with similar demographic and clinical characteristics, differing only as regards providers' surgical experience in the colorectal field. We focused on postoperative mortality and 5-year overall and cancer-specific survival. We also analyzed resection rates of the primary tumor and colostomy rates for patients with stage I to III rectal cancer, and use of (neo)adjuvant (chemo)radiation therapy for patients with stage II-III rectal cancer by surgeon's volume.

RESULTS

The analysis of these 2 study-groups shows better results for patients treated by colorectal-trained surgeons (high-volume surgeons) for each parameter taken into account: lower postoperative mortality (OR 0.32; 95% CI:0.7-0.1; p = 0.04), increased 5-year overall and cancer specific survival (rising from 41.2% and 46.4% to 56% and 61.2% respectively; OR 1.8; 95% CI: 1.3-2.6; p < 0.005). Patient treated by non specialized surgeons are more likely to receive a permanent colostomy (abdominoperineal resection: APR) (OR 5.9; 95% CI: 3.3-10.7) and to undergo a non-resective procedure (OR 4.8; 95% CI: 1.9-12)(p < 0.005). No difference was found between the 2 study-groups in the use of (neo)adjuvant (chemo)radiation therapy for patients with stage II-III rectal cancer.

CONCLUSIONS

Our analysis suggests that surgeon's volume does impact on outcomes for patients undergoing surgery due to colorectal cancer.

Enteric nervous system abnormalities in inflammatory bowel diseases

Various studies have described abnormalities of the enteric nervous system (ENS) in tissue samples from patients with chronic idiopathic inflammatory bowel diseases (IBD). The distribution of density of the different cell types of the ENS was however not studied in a systematic way. The aim of this study was to examine the density of neurons, enteroglial cells and interstitial cells of Cajal (ICC) in the different plexuses of the ENS in samples from patients with Crohn's disease (CD), ulcerative colitis (UC) and controls. Tissue samples from 16 patients with CD (ileum) and 16 patients with UC obtained in involved and non-involved areas were studied using immunohistochemistry with antibodies directed against neuron-specific enolase, S100, C-Kit and CD3. Sections were analysed blindly by two pathologists and the number of positive cells was counted for each type. Overall, an increase was noted for neuronal cell bodies, enteroglia and ICC in the deep muscular plexus in CD. In uninvolved areas of CD patients, the number of enteroglial cells was decreased. In UC, an increase of ICC in the muscularis propria and enteroglial cells was observed in diseased tissue. The study confirms the presence of abnormalities of the different cells of the ENS in IBD. The presence of lesions in samples from uninvolved areas, such as a reduction of enteroglia, supports a pathogenetic role of the ENS.

[Comparision between a bilio-pacreatic diversion with or without gastroresection after 2 years of follow-up in the treatment of the pathological obesity]

Malabsorptive bariatric procedures have a long history beginning with jejunoileal bypass, which was first performed in 1950s. The biliopancreatic diversion (BPD) has gained more prominence in Europe since its introduction by Scopinaro in 1976 The BPD has been modified and popularized by Hess in the United States and Marceau in Canada to include a sleeve gastrectomy and duodenal switch in order to decrease the incidence of marginal ulceration and iron deficiency anemia. Moreover the common channel was lengthened to 100 cm to decrease the incidence of long-term malnutrition. More recently Vassallo and coll. introduced a BPD associated with a transitory vertical gastroplasty (TGR). Aim of this study is to compare the results after 2 years follow-up in 15 obese patients who underwent the classical Scopinaro's BPD (group A) and 15 obese patients operated on BPD associated with TGR (group B).The mean preoperative BMI was 47.9 in the Group A and 48.6 in Group B. The BMI trend was after 6, 12 and 24 months: 39.1, 37.2, 33.1 in Group A and 37.3, 35.5, 31.4 in Group B. We observed in BPD+TGR one case of acute pancreatitis and 3 case of gastric paralysis in group A. No mortality was registered. Patients treated by BPD+TGR had better results in terms of weight loss and metabolic complications.

[The obstructive sleep apnea in bariatric surgery]

INTRODUCTION

Obesity is a well known risk factor for obstructive sleep apnea (OSA). Medical therapy is not effective for morbid obesity. Bariatric surgery is therefore a reasonable option for weight reduction for patients with clinically severe obesity.

PATIENTS AND METHODS

283 obese patients were operated on from 1999 until 2005 in our Institution and they were examined with a history, physical examination and the Epworth Sleepiness Scale (ESS). Obese patients with a ESS score > or = than 10 were evaluated with a Polysomnography (PSG).

RESULT

61 patients (21.5%) resulted with a ESS > or = than 10. An obstructive sleep apnoea syndrome was identified in 52 patients (85.2%). These patients were treated by continuous positive airway pressure (CPAP) for 3 months before the surgical treatment. After 1 year follow-up (100% of patients) we observed a reduction in OSAS patients: ESS < 10 in 77.5% and PSG negative in 80.3%.

CONCLUSION

This study considered the value of ESS to select obese patients with a high risk of OSA. We did not observe any association between grade of obesity and risk of OSA. Bariatric surgery reduced the prevalence of OSA already after 1 year of follow-up and the preoperative treatment of OSA (3 months CPAP) reduced the post-operative morbidity.

[Neurological and psychiatric disorders in primary hyperparathyroidism: the role of parathyroidectomy]

The clinical presentation of primary hyperparathyroidism (pHPT), previously constantly characterized by bone and renal diseases, has been changing during last years. Several Studies report psychic and behavioural symptoms mostly vague and aspecific, particular in elderly patients, such as asthenia, anxiety, depression, irritability, mood swings, amnestic and cognitive disturbances, severe psychosis. In case history hereby reported 11.8% of the patients affected by pHPT (16 out of 136 cases operated from 1983 to October 2006) who underwent to parathyroidectomy, presented only neuro-cognitive and/or psychiatric symptoms. A relevant association has been found between clinical presentation and age: patients showing neuro-cognitive and psychiatric disturbances were older compared to those suffering from the classical bone and kidney disease. No significant correlation neither with serum calcemia nor with PTH serum levels and severity of the symptomatology was demonstrated A statistically significant reduction of the anxious-depressive disturbances one month post surgery has been found (p < 0.05), and an improvement, though not significant, of the neuro-cognitive and psychiatric alterations was registered (p > 0.1). The Authors believe neuro-cognitive or psychic manifestations is not to be neglected, mainly in geriatric patients: frequently the aspecific symptomatology is not referred as hypercalcemia due to pHPT Neuro-psychic symptomatology should be considered an indication for surgical treatment.

Emergency surgery for complicated colorectal cancer. A two-decade trend analysis

BACKGROUND/AIMS

Emergency procedures for colorectal cancer have worse outcomes than elective resections. Temporal trends in emergency surgery are analyzed by comparing two decade-related series of colorectal cancer patients.

METHODS

The clinical data of 985 patients undergoing colorectal cancer surgery were collected during two decades (1975-1984 and 1995-2004). Rates of emergency surgery, operative mortality, 5-year cancer-related and overall survival were compared retrospectively.

RESULTS

The rate of emergency surgery decreased from 81 out of 513 cases (16%) during 1975-1984 to 41 out of 471 cases (9%) during 1995-2004 (p = 0.005). Over the same time, the rate of curative resections in emergency increased from 46% (37/81 cases) to 76% (31/41 cases) (p < 0.001), while patient and tumor characteristics remained similar. Operative mortality after emergency procedures decreased from 14% (11 deaths) to 5% (2 deaths) and cancer-related survival increased from 21 to 42% (p = 0.03). However, when excluding palliative procedures, survival after emergency surgery increased from 52 to 58%, while after elective treatment it increased from 56 to 78% (p < 0.001).

CONCLUSIONS

Frequency and operative mortality of emergency colorectal cancer surgery decreased substantially from 1975-1984 to 1995-2004. No significant improvement in long-term survival was observed when curative emergency resections only were considered. Further efforts are needed to reverse the diverging trend of long-term outcomes between emergency and elective curative procedures.

[Surgical treatment of primary hyperparathyroidism: our experience]

The Authors report their experience on 136 patients with primary hyperparathyroidism. Nephrolitiasis was proven in 56 patients (41.3%), 20 patients (14.7%) were asyntomatic. Acute primary hyperparathyroidism was detected in 12 cases (8.8%). The preoperative localization of the diseased glands permits to minimize the procedure in terms of length and region of incision, extent of exploration and morbidity. 91.3% of the lesions were single adenoma, 7.3% double adenomas and 1.4% hyperplasia in MEN 1. The intraoperative PTH assay, performed in 90 patients (66.2%), showed a sensibility of 93.4%. Surgical treatment was successful in 93.4% of cases ( 127/136 patients), increasing to 97.0% (132/136patients) if only recurrent hyperparathyroidism was considered, with no mortality and morbidity of 4.4%.

[Our experience in selecting patients for bariatric surgery]

AIM OF THE STUDY

To evaluate the parameters applied in Authors' experience for the selection of candidates undergoing bariatric surgery.

MATERIALS AND METHODS

A retrospective analysis has been performed of 447 patients who underwent bariatric surgery from December 1998 to December 2006 at the 1st Service of General Surgery of Spedali Civili of Brescia - Abdominal Surgical Department of University of Study of Brescia; 317 patients underwent a mal-absorptive procedure, 35 a gastro-restrictive procedure and 10 had a conversion from a gastro-restrictive procedure to a mal-absorptive one.

RESULTS

At 7 years of follow-up the Authors observed that the excess weight loss was 74.1% +/- 6.2 for mal-absorptive procedures and 42.3% +/- 2.6 for gastro-restrictive procedures. At 2 years of follow-up a progressive weight resumption was observed in the 20% of patients who had a gastro-restrictive procedures.

DISCUSSION AND CONCLUSIONS

Optimal clinical outcome were achieved confirming the belief that a strict and rigorous selection of the patients and the applied therapeutic algorithm have to be followed; though even more selective criteria can be suggested such as the preventive BIB. The clinical results supported our preference of mal-absorptive procedures (317 of 352 surgical performances, excepting the 10 conversions with an obliged surgical choice).

[Takayasu's arteritis in Crohn's disease: a case report]

The authors describe a case of Crohn's disease associated with Takayasu's arteritis. The coexistence of these two diseases has been previously reported in 28 subjects. The late onset of Crohn's disease, particularly in relation to that of the arteritis, and colonic involvement were peculiar features of the present case. Aetiopathogenetic theories regarding the association are discussed after reviewing previous case reports.

Colonic neuropathological aspects in patients with intractable constipation due to obstructed defecation

One of the most frequent subtypes of constipation is represented by obstructed defecation, and it has recently been reported that these patients may have colonic motor abnormalities in addition to alterations of the anorectal area. However, it is unknown whether these patients display abnormalities of the enteric nervous system, as reported in other groups of constipated subjects. For this reason, we evaluated the neuropathologic aspects of the enteric nervous system in a homogeneous group of patients with obstructed defecation. Colonic specimens from 11 patients (nine women, age range 39-66 years) undergoing surgery for symptoms refractory to any therapeutic measure, including biofeedback training, were obtained and examined by means of conventional histological methods and immunohistochemistry (NSE, S100, c-Kit, formamide-mAb, Bcl-2, CD34, alfa-actin). Analysis of the specimens showed that the enteric neurons were significantly decreased only in the submucosal plexus of patients (P<0.0001 vs controls), whereas the enteric glial cells of constipated patients were reduced in both the myenteric (P=0.018 vs controls) and the submucosal plexus (P=0.004 vs controls). No difference between patients and controls were found concerning c-Kit and CD34 expression, and the number of apoptotic neurons. These findings support the concept that at least a subgroup of patients with obstructed defecation and severe, intractable symptoms display abnormalities of the enteric nervous system, mostly related to the enteric glial cells. These findings might explain some of the pathophysiological abnormalities, and help to better understand this condition.

[Accuracy and acceptability of surveillance tests after total colectomy and ileorectal anastomosis]

BACKGROUND AND AIMS

Surveillance of the rectal stump after total colectomy for familial adenomatous polyposis (FAP) or chronic ulcerative colitis (CUC) is empirically based on periodic outpatient visit with digital exploration and proctoscopy. Exfoliative cytology is supported as a complementary tool of investigation. The aim of present study is to compare accuracy and acceptability of the above mentioned tests.

PATIENTS AND METHODS

Forty patients who underwent total colectomy were prospectively enrolled, including 12 FAP patients, 16 CUC patients, 12 patients with slow-transit constipation. Each patient underwent digital exploration of the rectum, proctoscopy with eventual biopsy and rectal lavage with exfoliative cytology. Diagnostic accuracy rates were calculated for the dysplastic/polypoid and inflammatory findings. A structured questionnaire was used in order to evaluate patient acceptability of each test.

RESULTS

Sensitivity and specificity for inflammatory lesions was higher using proctoscopy and biopsy (1000% and 100%, respectively) than using exfoliative cytology (87% and 92%, respectively) or digital exploration (870% and 880%, respectively). Sensitivity and specificity for dysplastic/polypoid lesions was higher using proctoscopy and biopsy (91% and 100%, respectively) than using exfoliative cytology (50% and 83%, respectively) or digital exploration (50% and 97%, respectively). Mean acceptability score of proctoscopy (3.29) was substantially lower than those of digital exploration (4.29), and of exfoliative cytology (4.38). Only 2.5% of patients preferred proctoscopy on alternative tests.

CONCLUSIONS

At present, proctoscopy with biopsy remains the most accurate test for surveillance of the rectal stump, however a significant proportions of patients consider it scarcely acceptable. A negative impact on surveillance protocol compliance is consecutively anticipated.

Prognostic value of circulating KRAS2 gene mutations in colorectal cancer with distant metastases

While tissue KRAS2 mutations have been extensively investigated, the role of circulating mutant KRAS2 gene in patients with colorectal carcinoma remains obscure. The aim of the present study was to explore the prognostic significance of circulating KRAS2 gene mutational status in subjects undergoing primary treatment for colorectal cancer. Codon 12 KRAS2 mutations were examined in DNA samples extracted from the serum of 86 patients with colorectal cancer and were compared with the KRAS2 status of their primary tumors. Tissue and serum KRAS2 status was compared with other clinicopathological variables (including CEA and CA 19-9 levels) and with cancer-related survival. KRAS2 mutations were found in tissue samples of 28 patients (33%); serum KRAS2 mutations were detected in 10 of them (36%). Serum KRAS2 status was significantly associated with Dukes' stage D (p=0.001) and with preoperative CA 19-9 levels (p=0.01). At multivariate analysis, cancer-related survival was associated with Dukes' stage (p<0.0001), CEA level (p=0.02), and mutant circulating KRAS2 (p=0.01). All 7 stage D patients with serum KRAS2 mutations died of the disease within 24 months of primary treatment; cancer-related survival was significantly better in 9 stage D patients without serum KRAS2 mutations, with 5 patients (56%) alive after 24 months and 1 patient (13%) alive after 44 months. Residual disease after surgery was evident in all 7 stage D patients with mutant circulating KRAS2, and in 5 out of 9 stage D patients without serum mutations. Serum KRAS2 status may impact substantially on the management of stage D colorectal carcinoma, since it appears to cor-relate with prognosis in this patient subgroup.