Charbel Chater

Giant colon diverticulum

Giant colonic diverticulum is defined by a diverticulum whose diameter is greater than 4 cm. This is a rare entity, arising mainly in the sigmoid colon. The diagnosis is based on abdominal computed tomography that shows a gas-filled structure communicating with the adjacent colon, with a smooth, thin diverticular wall that does not enhance after injection of contrast. Surgical treatment is recommended even in asymptomatic diverticula, due to the high prevalence and severity of complications. The gold standard treatment is segmental colectomy. Some authors propose a diverticulectomy when the giant diverticulum is unique.

Reemergence of Splenectomy for Itp Second-line Treatment?

Introduction: Corticosteroids are still the standard first-line treatment for immune thrombocytopenic purpura (ITP). As second-line therapy, splenectomy and Rituximab are both recommended. The aim of our study was to compare the efficacy of Rituximab to splenectomy in persistent or chronic ITP patients. Methods: Between January 1999 and March 2015, we retrospectively selected all consecutive patients who underwent an ITP second-line treatment: Rituximab or splenectomy. The distinction between open (OS) and laparoscopic splenectomy (LS) was analyzed. Primary outcome was composite: hospitalization for bleeding and/or thrombocytopenia and death from hemorrhage or infection. Secondary outcomes were based on response (R) and complete response (CR) rates as defined by the American Society of Hematology. Results: Ninety-six patients were included: 30 patients received Rituximab, 37 underwent OS, and 29 underwent LS. The follow-up was 30, 60, and 120 months in Rituximab, LS, and OS groups, respectively. At 30th month, the primary outcome-free survival rate was higher in splenectomy groups (84% for OS, 86% for LS) than Rituximab group (47%) (P = 0.0002). Similarly, at 30th month, R and CR rates were higher for OS (86.5% and 75.7%, respectively) and LS groups (93.1% and 89.7%) than Rituximab (46.7% and 30%) (P = 0.0001). Moreover, R rates remained elevated at 60th month for OS and LS groups (83.7% and 89.6% respectively) and 78.4% at 120th month for OS group. Conclusion: We observed that splenectomy for ITP second-line treatment was more effective than Rituximab regarding maintenance of R, CR, and overall response rates. OS and LS had similar efficacy.

Post-operative recurrence of Crohn’s disease after definitive stoma: an underestimated risk

IntroductionCrohn’s disease (CD) is a progressive inflammatory disease affecting the entire gastrointestinal tract. The need for a definitive stoma (DS) is considered as the ultimate phase of damage. It is often believed that the risk of further disease progression is small when a DS has been performed.AimsThe goals of the study were to establish the rate of CD recurrence above the DS and to identify predictive factors of CD recurrence at the time of DS.MethodsWe retrospectively reviewed all medical records of consecutive CD patients having undergone DS between 1973 and 2010. We collected clinical data at diagnosis, CD phenotype, treatment, and surgery after DS and mortality. Stoma was considered as definitive when restoration of continuity was not possible due to proctectomy, rectitis, anoperineal lesions (APL), or fecal incontinence. Clinical recurrence (CR) was defined as the need for re-introduction or intensification of medical therapy, and surgical recurrence (SR) was defined as a need for a new intestinal resection.ResultsEighty-three patients (20 males, 63 females) with a median age of 34xa0years at CD diagnosis were included. The median time between diagnosis and DS was 9xa0years. The median follow-up after DS was 10xa0years. Thirty-five patients (42%) presented a CR after a median time of 28xa0months (2–211) and 32 patients (38%) presented a SR after a median time of 29xa0months (4–212). In a multivariate analysis, APL (HRxa0=xa05.1 (1.2–21.1), pxa0=xa00.03) and colostomy at time of DS (HRxa0=xa03.8 (1.9–7.3), pxa0=xa00.0001) were associated factors with the CR.ConclusionAfter DS for CD, the risk of clinical recurrence was high and synonymous with surgical recurrence, especially for patients with APL and colostomy.

Greatly Enlarged Thickened Gallbladder

A woman in her 60s presented to the hospital because she felt abdominal pain and increasing asthenia during the previous 4months. She reported a weight loss of 40 kg during the previous 12 months concomitant with depression. The patient had a history of cardiac arrhythmia, hypertension, and sigmoidectomy for diverticulitis. Medications included lasilix, amlodipine, amiodarone, and atenolol. On examination, the patient appeared well. Her vital signs were normal. The abdomen was soft without distension. A positive Murphy sign was observed. Her white blood cell count was 11400/μL (to convert to ×109/L, multiply by 0.001), her hemoglobin level was 11.5 g/dL (to convert to g/L, multiply by 10.0), and her platelet count was 233 ×103/μL (to convert to ×109/L, multiply by 1.0). The C-reaction protein level was elevated to 41 mg/L (to convert to nmol/L, multiply by 9.524). The results of renal and liver function, coagulation, blood level of electrolytes, total protein, albumin, antigen carcino embryonnaire, carbohydrate antigen 19-9, carbohydrate antigen 125, and β2microglobulin tests were normal. The patient had a normal esophagogastroduodenoscopy and colonoscopy. Ultrasonography revealed a 10 × 8-m mass in the right hypochondrium. Abdominal computed tomography scan revealed a thickened gallbladder wall infiltrating the liver parenchyma. There were 3 perihepatic lymph nodes. Magnetic resonance imaging showed a greatly enlarged gallbladder with a thickened wall without invading adjacent structures, a continuous mucosal line, and a hypoattenuated intramural nodule (Figure 1). Figure 1. Axial abdominal magnetic resonance image.

Chronic radiation enteritis

Radiation enteritis is an iatrogenic disease of the intestines caused by radiation therapy. Two entities, chronic and acute radiation enteritis, are described. The acute symptoms (abdominal pain, loss of appetite, diarrhea) develop within the first hours or days after radiation therapy and can be treated medically. Chronic radiation enteritis leads to a chronic sub-obstructive and/or malabsorption syndrome developing at least two months after the end of radiation therapy. Cases occurring 30 post-radiation are reported. Treatment is surgical with extended resection of all involved elements of the digestive tract and ileocolonic anastomosis in healthy zones. The diagnosis is confirmed by the anatomopathology report of fibrous intestinal lesions associated with obliterating arterial lesions.

Intraplatelet Vascular Endothelial Growth Factor and Platelet-Derived Growth Factor: New Biomarkers in Carcinoembryonic Antigen-Negative Colorectal Cancer?

Background/Aim: Colorectal cancer (CRC) is associated with high incidence and mortality rates. Carcinoembryonic antigen (CEA), a prognostic biomarker for recurrent CRC following curative resection, suffers from low sensitivity, especially in early-stage screening. Intraplatelet angiogenesis regulators (IPAR), such as vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF), have been identified as important regulators of tumor growth in CRC. The aim of this study was to confirm the higher preoperative level of IPAR (VEGF and PDGF) in CRC patients compared to controls and to measure IPAR in CEA-negative CRC patients. Methods: The data and blood of 30 CRC patients and 30 presumably healthy controls were prospectively analyzed and compared. Results: We confirmed elevated preoperative intraplatelet VEGF and PDGF levels in CRC patients compared to controls. Importantly, IPAR were significantly elevated even in CEA-negative CRC patients. Conclusion: Elevated preoperative intraplatelet VEGF and PDGF levels in CRC patients suggest new possibilities for postoperative monitoring in CRC patients, especially when CEA is negative.

Développement d’un modèle de récidive post chirurgicale de la maladie de Crohn chez le rat HLAB27

L’origine de la maladie de Crohn reste inconnue. La recidive preanastomotique (RPA) post chirurgicale est frequente et son mecanisme est mal connu. Aucun modele animal ne mime les lesions inflammatoires de la recidive. L’objectif de cette etude est de developper un modele animal reproductible de RPA chez le rat HLA B27. Nous avons utilise des rats transgeniques HLA B27 et des rats sauvages (HLA B27 -). Les rats randomises en aveugle ont eu une resection-anastomose ileo-colique (RIC), une section-anastomose grelo-grelique (SAG) ou une laparotomie blanche (LB). Les animaux ont ete suivi cliniquement jusqu’au sacrifice a 6 semaines post operatoire ou des prelevements digestifs pour l’histologie et la biologie moleculaire et de feces pour la bacteriologie, ont ete realises. Cent trois rats ont ete operes avec une survie de 60 %. Les rats operes du groupe RIC et SAG avaient une perte de 10% du poids jusqu’au 7e jour post operatoire. A 6 semaines, les rats transgeniques RIC ont developpe des ulcerations macroscopiques preanastomotiques. Il n’a pas ete constate de lesions chez les rats non transgeniques. Aucune lesion n’a ete objectivee quel que soit le genotype dans les groupes SAG et LB. Les analyses bacteriologique, histologique et de biologie moleculaire sont en cours. Le rat transgenique HLA-B27 semble developper une ileite preanastomotique mimant la recidive. Ce modele permettrait d’evaluer des molecules therapeutiques et de comprendre la physiopathologie de la recidive. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.