Cesare Ruffolo

A systematic review on the clinical diagnosis of gastrointestinal stromal tumors

The aim of this work was to assess the prevalence of symptoms of gastrointestinal stromal tumors (GISTs) and the diagnostic yield of clinical procedures for its diagnosis.

Health-related quality of life after restorative proctocolectomy for ulcerative colitis: Long-term results

Restorative proctocolectomy (RPC) is the favorite operation for ulcerative colitis, but it may influence health-related quality of life (HRQL). Our aims were to determine the long-term HRQL of patients and its modifications after a 5-year follow-up and to identify any risk factor for a worse outcome. We enrolled 36 patients submitted to RPC (mean followup 8.4 ± 4.7 years), 36 ulcerative colitis (UC) patients, and 36 healthy subjects. We used a previously validated questionnaire that explored bowel symptoms, systemic symptoms, emotional function, and social function. A series of 17 patients had completed the same questionnaire 5 years earlier. Clinical and surgical factors were investigated. Statistical analysis was performed with Student’s t-test, Wilcoxon matched-pairs test, and Fisher’s exact test. The scores of the RPC patients were significantly better than those of moderate or severe UC patients, similar to those with remission/ mild UC, and higher than those of the controls. The scores of patients interviewed 5 years earlier did not change in the present study, except for patients during the first postoperative year, in whom the scores were now significantly better. The analysis of RPC patients in subgroups showed that the use of drugs, high stool frequency, pouchitis, pelvic complications, and younger age at UC diagnosis worsened the HRQL outcome. We concluded that RPC patients, after a long-term follow-up, had an HRQL similar to that of the remission/mild UC patients. Recently operated patients improved their quality of life mainly because of improved emotional function, and patients who had been operated on for a longer time maintained their HRQL. HRQL is influenced by drugs, stool frequency, pouchitis, postoperative pelvic complications, and age at diagnosis.RésuméLa coloprotectomie restauratrice (CPR) est l’intervention préférée dans la rectocolite ulcéro-hémorragique (RCUH), mais elle peut avoir un retentissement sur la qualité de vie (QV). Nos objectifs ont été de déterminer la QV des patients à long terme ainsi que leurs modifications après un suivi de 5 ans et d’identifier les facteurs de risque pour une évolution non favorable. Nous avons analysé les résultats concernant 36 patients ayant eu une CPR (suivi moyen: 8.4 ± 4.7 ans) pour avecRCUH 36 patients avec RCUH et 36 patients de contrôle. Nous avons utilisé un questionnaire validé antérieurement qui explore les symptômes intestinaux, les symptômes systémiques, les fonctions émotionnelle et sociale. Dix-sept patients avaient complété ce même questionnaire cinq ans plus tôt. On a également examiné les facteurs cliniques et chirurgicaux. L’analyse statistique a été réalisée par le test t de Student, de Wilcoxon pour les données appariées et le test exact de Fisher. Les patients CPR ont obtenu des scores significativement plus élevés que les patients présentant une RCUH modérée ou sévère, similaires à ceux présentant une RCUH en rémissionpeu sévère et plus élevés que les patients de contrôle. Les scores des patients interviewés cinq ans plus tôt n’ont pas changé sauf pour la première année postopératoire pendant laquelle il était significativement meilleur. L’analyse des sous-groupes de patients RCUH a montré que l’utilisation des medicaments, une fréquence élevée de l’évacuation, la pouchite, les complications pelviennes et un âge peu élevé au moment de l’intervention ou diagnostic a aggravé l’évolution de la QV. En conclusion, les patients ayant du eu une CPR au long cours jouissent d’une QV similaire à celle des patients en rémission ou avec une RCUH peu sévère. Les patients opérés récemment voient leur QV améliorée principalement en raison de leur fonction émotionnelle alors que les patients opérés il y a plus long temps gardent leur QV. La QV est influencée par l’utilisation des medicaments, la fréquence des selles, la pouchite, les complications postopératoires et l’âge au moment du diagnostic.ResumenLa proctocolectomía restaurativa (PCR) es el tipo de cirurgia en el tratamiento de la colitis ulcerativa, pero puede afectar la calidad de vida al comparla con el buen estado de salud (CVCS). Nuestro propósito fue determinar la CVCS a largo plazo y sus cambios después de S años de seguimiento, identificando factores de riesgo de empeoramiento. Se incorporaron 36 pacientes sometidos a PCR (promedio de seguimiento: 8.4 ± 4.7 años) 36 por colitis ulcerativa (CU), y 36 pacientes sanos. Se utilizó un cuestionario previamente validado para identificar síntomas intestinales, síntomas sistémicos, estado emocional y cualidad de vida en el ambito social. Diecisiete pacientes habían respondido el mismo cuestionario 5 años antes. Factores clínicos y quirúrgicos fueron investigados. Se hizo el análisis estadístico mediante la prueba de Student y las pruebas de apareamiento de Wilcoxon y de exactitud de Fischer. Los pacientes con PCR registraron valores significativamente mejores que los de los pacientes con colitis ulcerativa moderada o severa, una tasa similar a remisión de CU leve y más alta que la de los controles. Los valores de los pacientes entrevistados 5 años antes no mostraron cambio, y sólo aquellos en el primer año postoperatorio registraron ahora mejores valores. El análisis de los subgrupos de pacientes con PCR puso en evidencia que el requerimiento de drogas, la alta frecuencia en la defecatión, la “bolsitis” (pouchitis) las complicaciones pélvicas y la edad más joven en el momento del diagnóstico, desmejoraban la CVCS. En conclusión, los pacientes sometidos a PCR en el seguimiento a largo plazo logran una CVCS similar a la de aquellos con remisión de CU leve. Los pacientes recientemente operados mejoraron su calidad de vida principalmente por causa de un mejor estado emocional, en tanto que los operados con más anterioridad mantienen su CVCS. La CVCS se ve influenciada por el requerimiento de la droga, la frecuencia en la defecatión, la “bolsitis,” las complicaciones pélvicas postoperatorias y la edad en el momento del diagnóstico.

Surgical predictors of recurrence of Crohn’s disease after ileocolonic resection

Background/aimsAnastomotic recurrence after bowel resection is a major problem in Crohn’s disease (CD) surgery. The aims of this retrospective study are to assess the role of anastomotic configuration, the type of suture and the type of surgical approach (laparoscopy-assisted vs laparotomy) in CD recurrence. Secondary end points were to identify any possible predictor that would help the selection of patients for medical prophylaxis.Materials and methodsIn this retrospective study, we enrolled 141 consecutive patients who had undergone ileocolonic resection for CD. Univariate actuarial analysis was performed according to demographic, clinical and surgical predictors. Variables that resulted to be significant at the univariate analysis were included in two multivariate Cox proportional hazards models that analyzed symptomatic and surgical recurrence, respectively.ResultsIn the long-term, handsewn side-to-side anastomosis reported a significantly lower surgical recurrence rate than stapled end-to-side (p < 0.05). At multivariate analysis, anastomosis type, surgical and intestinal complications (p < 0.01) and age at CD onset (p < 0.05) resulted to be significant predictors for re-operation for CD recurrence. Multivariate analysis showed that surgical complication was also a significant predictor of symptomatic recurrence.ConclusionsSide-to-side anastomosis configuration seems to delay re-operation and can be assumed as the standard configuration in ileocolonic anastomosis in CD. Post-operative complications and young age at disease onset might be a signal of aggressive CD that may warrant prophylactic pharmacological therapy.

Follow-Up of Exocrine Pancreatic Function in Type-1 Diabetes mellitus

In a previous study, mild to moderate exocrine pancreatic insufficiency, as measured by the secretin-pancreozymin test, was found in 23 (43%) of 53 patients with type-1 diabetes mellitus. Of these 53 patients, 20 (7 of whom initially had an abnormal secretin-pancreozymin test) were available for a follow-up examination 11 years later. Of the 7 patients with abnormal exocrine pancreatic function at the first test, 5 remained abnormal and 2 became normal, whereas of the 13 patients with initially normal pancreatic function the test result remained normal in 11 patients and became abnormal in 2. In these 2 groups the test result did not differ significantly between both tests. However, exocrine pancreatic function had returned to normal or had become abnormal in 2 patients, respectively, at the second test. In the 3 patients with exocrine pancreatic insufficiency at the first and second tests, the lipase level had not fallen below 10% or less than the normal level at which steatorrhea occurs and therapy is required. There was no significant correlation between the duration of the diabetes and the test results for both time points of investigation. The data suggest that mild to moderate exocrine pancreatic insufficiency found in type-1 diabetes is due to an early event in the course of the diabetes and does not progress. Therefore, this finding is of minor clinical importance and expensive pancreatic enzyme substitution will not be required.

A systematic review on advancement flaps for rectovaginal fistula in Crohn’s disease: transrectal vs transvaginal approach

Aim  Despite advances in the treatment of Crohn’s disease (CD), the treatment of rectovaginal (RV) fistula remains challenging. Transrectal (RAF) and transvaginal advancement flaps (VAF) represent two possible alternative surgical approaches to this problem. The study aims to review and compare the results of these approaches for RV fistula in CD.

Gastrointestinal stromal tumors: Report of an audit and review of the literature

Gastrointestinal stromal tumors (GISTs), tumors characterized by c-KIT mutations, are the most frequent mesenchymal tumors of the digestive tract. The stomach is the most commonly involved site. Localization, size and mitotic rate are reliable predictors of survival and the two milestones of GISTs treatment are surgery and imatinib. This article is aimed to report the data of an audit, carried out on the morphological and clinical aspects of the disease and to review the present knowledge on GISTs. A total of 172 patients with GISTs (M : F=1 : 1; mean age 65 years) were recruited. The stomach was the most frequently involved site. In 50% of the cases the tumor was smaller than 5 cm, whereas major symptoms were observed in 43% of the cases. Predictors of progressive disease were present only in a small percentage of cases but the disease was in the metastatic phase in over 25% of the cases at diagnosis. Familial aggregation was rare but a consistent share of the patients (21%) had other synchronous or metachronous cancers. The most frequent mutations were in-frame deletions and point mutations of c-KIT exon 11. This report confirms in part the available data on GIST in a consecutive series of patients recruited in Italy and shows that only large collaborative multicenter studies provide data sound enough to enable making reasonable clinical and therapeutic choices, and suggests that, as a measure of secondary prevention, a diagnostic definition should be obtained in all submucosal lesions of the GI tract and that GIST patients should be screened for second tumors.

Plasma lipids and inflammation in active inflammatory bowel diseases

Background  Ulcerative colitis (UC) and Crohn’s disease (CD) can cause metabolic and inflammatory alterations.

Results of iterative surgery for persistent and recurrent parathyroid carcinoma

Background and aimsParathyroid carcinoma (PC) is a rare cause of primary hyperparathyroidism. Surgery is the only effective treatment; re-operations are often required, because recurrences occur in most of the cases. The aim of this retrospective study was to analyse the rate of biochemical cure, clinical relief, sensitivity of localizing studies and morbidity after re-operations.Patients and methodsFrom January 1980 to December 2000, 19 patients underwent surgery for PC. PC persisted or recurred in all cases. Fourteen re-operations were performed in six patients.ResultsTwelve re-operations at loco-regional site and two pulmonary metastasectomies were performed. Iterative surgery achieved a symptomatic relief in 86% of cases and a transient biochemical remission only in one patient, but significantly reduced parathormone and calcemia. The sensitivity of scintigraphy, CT and ultrasonography was 86, 79 and 100%, respectively.ConclusionWhen recurrences occur, complete cure of PC is unlikely, despite re-operations. Iterative surgery is associated with some morbidity and never achieves a definitive cure, but provides significant clinical and biochemical palliation. Localizing studies are mandatory but do not detect all recurrences.

The role of CD40 in ulcerative colitis: histochemical analysis and clinical correlation.

Objectives CD40 co-stimulator seems to be implicated in the loss of tolerance against self-antigens in many autoimmune diseases. The evidence suggests that in the pathogenesis of ulcerative colitis there is an activity state against self-antigens of the gut wall and flora. The aim of this study was to analyse the expression of CD40 in ulcerative colitis, comparing it with Crohns disease and nonspecific inflammation of the colon and to determine whether there is a relationship between its expression and the activity stage of the disease. Methods The expression of CD40 in the colonic samples of 51 patients (30 ulcerative colitis, 9 Crohns disease and 12 nonspecific inflammation) was analysed by immunohistochemistry. Twenty-four patients with ulcerative colitis were scored according to clinical, endoscopic and histological classification. Results The mean percentage of CD40+ cells per field in the colonic mucosa was: ulcerative colitis 21 ± 11%, Crohns disease 24 ± 9%, nonspecific inflammation 7 ± 7%. The ulcerative colitis patients were statistically significantly different compared to the patients with nonspecific inflammation (P < 0.005), even when comparing the patients in remission (P < 0.05). The expression in Crohns disease was similar to that in ulcerative colitis. The expression of CD40 in ulcerative colitis was directly proportional to the state of activity of the disease according to the clinical (P < 0.02), endoscopic (P < 0.01) and histological (P < 0.02) criteria. Conclusions The expression of CD40 in the colonic mucosae of patients with ulcerative colitis is significantly increased and is proportional to the state of activity. The results seem to confirm the hypothesis that a loss of tolerance could be involved in the pathogenesis of this disease.

Relationship between mucosa-associated microbiota and inflammatory parameters in the ileal pouch after restorative proctocolectomy for ulcerative colitis

BACKGROUND Our aim was to assess the relationship between the ileal-pouch microbiota and inflammatory parameters in patients operated on for ulcerative colitis. METHODS In this cross-sectional study, 32 consecutive outpatients returning for follow-up endoscopy were recruited. Pouch biopsies were obtained during endoscopy for culture of bacteria adherent to the mucosa, histology, and analysis of local inflammation (IL-1β, IL-6, and TNFα by immunometric assay; and toll-like receptor [TLR] 2 and 4 mRNA by quantitative real-time PCR). Fecal samples were collected for analysis of lactoferrin by ELISA. RESULTS Granulocyte and monocyte mucosal infiltration correlated directly with mucosal Bacteriodiaceae spp. counts. Clostridiaceae spp. counts showed a direct correlation with mucosal ulceration and number of daily stools. In patients with pouchitis, Enterococcaceae spp. counts were less than in healthy patients. Enterobacteriaceae spp., Streptococcaceae spp. and Enterococcaceae spp. counts correlated inversely with immune cell infiltration. TLR-2 and TLR-4 mRNA, and mucosal levels of IL-1β levels all correlated directly with Veilonella spp. counts. CONCLUSION Bacteriodaceae spp. and, Clostridiaceae spp. may be associated with inflammation of the pouch mucosa. Conversely, Enterococcaceae spp., and possibly Enterobacteriaceae spp. and Streptococcaceae spp., may have an active role in maintaining immunologic homeostasis within the pouch mucosa.