Davide F. D’Amico

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.

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.

The survival benefit of liver transplantation in hepatocellular carcinoma patients.

BACKGROUND There are no studies evaluating the survival benefit of liver transplantation over alternative therapies for patients with hepatocellular carcinoma. METHODS The short- to mid-term survival benefit (study group=135 aggressively treated patients with hepatocellular carcinoma, 52% beyond Milan criteria at pathology) was calculated by comparing the mortality rates of liver transplantation vs alternative therapies patients. A Markov prediction model was then created to estimate the long-term survival benefit of liver transplantation (gain in life expectancy) over alternative therapies. The long-term survival rates in the liver transplantation group were calculated using the Metroticket website calculator (http://89.96.76.14/metroticket/calculator/). RESULTS The short- to mid-term analysis indicated that liver transplantation afforded no significant survival benefit in the group of patients with hepatoma as a whole (hazard ratio=1.229, 95% confidence interval 0.544-2.773, p=.6200). The benefit was concentrated in patients with a poor initial response to alternative therapies (hazard ratio=3.137, 95% confidence interval 1.428-6.891, p=.0044). In the long-term analysis, the gain in life expectancy of liver transplantation vs alternative therapies was 6.115 years (base-case analysis) and the main determinants of gain in life expectancy were the 5-year survival prospects after alternative therapies and the patients age. CONCLUSIONS The survival benefit of liver transplantation for patients with hepatocellular carcinoma is strongly related to the patients age and the effectiveness of available alternative therapies.

Health-Related Quality of Life after Colonic Resection for Diverticular Disease: Long-term Results

Background and AimsWhile colonic resection is standard practice in complicated colonic diverticular disease (DD), treatment of uncomplicated diverticulitis is, as yet, unclear. The aim of the present study was to evaluate the long-term clinical outcome and quality of life in DD patients undergoing colonic resection compared to those receiving medical treatment only.Patients and MethodsSeventy-one consecutive patients who were admitted to our surgical department with left iliac pain and endoscopical or radiological diagnosis of DD were enrolled in this trial. Disease severity was assessed with Hinchey scale. Twenty-five of the patients underwent colonic resection, while 46 were treated with medical therapy alone. After a median follow-up of 47 (3–102) months from the time of their first hospital admission, the patients responded to the questions of the Cleveland Global Quality of Life (CGQL) questionnaire and to a symptoms questionnaire during a telephone interview. Admittance and surgical procedures for DD were also investigated, and surgery- and symptoms-free survival rates were calculated. Nonparametric tests and survival analysis were used.ResultsThe CGQL total scores and symptom frequency rate were found to be similar in the two groups (resection vs nonresection). Only current quality of health item was significantly worse in patients who had undergone colonic resection (p = 0.05). No difference was found in the rate and in the timing of surgical procedures and hospital admitting for DD in the two groups. In particular, the nine patients classified as Hinchey 1 who underwent surgery reported the same quality of life, symptoms frequency, operation, and hospital admitting rate as those who had been admitted with the same disease class but who received medical treatment only.ConclusionsOur results indicate that there does not seem to be any long-term advantage to colonic resection which should be considered only in patients presenting complicated DD.

Cytokine network in chronic perianal Crohn's disease and indeterminate colitis after colectomy.

Antitumor necrosis factor alpha (anti-TNF-α) therapy in perianal Crohn’s disease (CD) is widely established but recent studies suggest that the underlying fistula tract and inflammation may persist. Treatment with a monoclonal antibody against interleukin (IL)-12 was reported to induce clinical responses and remissions in patients with active CD. The aim of our study was to analyze the cytokine network (TNF-α, IL-12, IL-1β, and IL-6) in 12 patients with chronic perianal CD and a Crohn’s disease activity index (CDAI) score <150 to exclude active intestinal disease, in 7 patients with indeterminate colitis (IC) after restorative proctocolectomy with perianal complications, in 7 patients with active intestinal CD without perianal manifestations, and in 19 healthy controls. Nonparametric Mann–Whitney U test and Spearman’s rank correlation test were used. Serum TNF-α levels were significantly higher in patients with IC than perianal CD patients and healthy controls. Serum TNF-α levels significantly correlated with perianal CDAI score and with the presence of anal fistulas. Serum IL-12 levels correlated with the presence of anal strictures and were similar in all groups. Serum IL-6 levels were significantly higher in the presence of perianal fistulas and lower in the presence of anal strictures. Our study confirmed that TNF-α plays a major role in the perianal and intestinal CD. Furthermore, the significantly higher TNF-α serum levels in patients with IC suggest the use of anti-TNF-α in such patients. On the contrary, according to our results the efficacy of anti-IL-12 antibodies appears doubtful in chronic perianal CD or IC without anal strictures. The role of IL-6 as a systemic mediator for active chronic inflammation was confirmed and a possible role for its monoclonal antibody was suggested.

High-Energy Laser Therapy of Barrett's Esophagus: Preliminary Results

Abstract.We present the preliminary results obtained by our research group utilizing Nd:YAG and diode lasers to treat Barrett’s esophagus (BE). A total of 15 patients with BE (mean age 58 years) underwent endoscopic laser therapy: 11 with intestinal metaplasia, 2 with low-grade dysplasia, and 2 with high-grade dysplasia. The mean length of BE was 4 cm (range 1–12 cm). Six of these patients also underwent antireflux surgery, and nine were prescribed acid-suppressive medication. Endoscopic Nd:YAG laser treatment was carried out from 1997 to 1999; thereafter, diode laser was employed. The mean follow-up of these patients after the first laser session was 28 months. Patients underwent a mean of 6.5 laser sessions (range 3–17 sessions), with no apparent complications. The mean energy per session was 1705 JJ. Only six of these patients (40%) showed complete endoscopic and histologic remission, but a mean of 77% (SD 23.8%) of the total metaplastic tissue in all these patients was ablated. The percentage of healed mucosa was higher in patients with short-segment BE (92%) (p < 0.05) and in subjects treated by two or more laser sessions per centimeter of BE length (89%) (p < 0.05). All four patients with dysplasia showed histologic regression to nondysplastic BE or to squamous epithelium, without recurrence during a mean follow-up of 30 months. The patients who underwent antireflux surgery and those prescribed pharmacologic treatment had similar results. Nd:YAG and diode laser treatment of BE is a safe, effective procedure; it required two sessions per centimeter of metaplasia; and it achieved complete regression of the dysplasia. Further studies are necessary to quantify its effect on cancer incidence.

Cystadenoma and laparoscopic surgery for hepatic cystic disease: a need for laparotomy?

BackgroundThis study aimed to evaluate the incidence of cystadenoma diagnosis in a series of laparoscopic treatments for nonparasitic liver cysts, as well as its management.MethodsFrom 1996 to 2004, 26 patients with a nonparasitic cyst of the liver were selected for laparoscopic liver surgery. Solitary nonparasitic liver cysts were, whenever feasible, completely enucleated.ResultsIn four patients, the histopathologic examination showed a cystadenoma. Three patients with 13, 9, and 12-cm cysts, respectively, had undergone complete enucleation of the lesion, with no evidence of recurrence in the follow-up visit. One patient with multicystic liver experienced a recurrence and required an open hepatic resection.ConclusionsWhen a complete laparoscopic enucleation of the cyst can be ensured, a strict follow-up assessment should be considered as the definitive treatment, with surgical intervention demanded only in the case of recurrence or high suspicion for malignancy.

B1a lymphocytes in ulcerative colitis

Background and aimsB1a lymphocytes (CD5+) are the major contributors of natural antibodies (Ab) implicated in the initial protection against several infections. The aim of this study was to assess the expression of these cells in the peripheral blood of ulcerative colitis (UC) patients who underwent restorative proctocolectomy (RPC) and others who were not operated on.Materials and methodsThe blood concentration of CD5+ B cells was analysed by three-colour flow cytometry. Blood was collected from 38 UC patients, 20 of whom had undergone RPC and compared with the results in 18 healthy controls and in 12 familial adenomatous polyposis (FAP) patients who had undergone RPC. We were interested in evaluating if there was any correlation between B1a blood cell concentration and ESR and CRP levels, clinical, endoscopic and histological activity, perinuclear anti-neutrophil cytoplasmic antibody (pANCA) and extra-intestinal symptoms.ResultsB1a cell blood concentration was reduced in non-operated UC patients (20.7 ± 4.6/μl) with respect to that in healthy controls (71.1 ± 18.0/μl, p < 0.05). It was also lower in UC patients with RPC (24.9 ± 1.0/μl) compared to RPC for FAP (48.2 ± 6.2, p < 0.05). B1a cell rate correlated inversely in UC patients with ESR (R = −0.41, p < 0.05) and CRP levels (R = −0.47, p = 0.01).ConclusionB1a cell concentration was reduced in the blood of patients with UC even after the diseased organ was surgically removed by proctocolectomy. As these cells play an important role in natural immunity against luminal stimuli, consistently lower levels that are found in UC patients could be responsible for the impaired immunologic response to gut antigens in this disease.

Early Surgery for the Treatment of Toxic Megacolon

Background: Toxic megacolon (TM) is a potentially lethal complication of idiopathic inflammatory bowel disease or infectious colitis, characterized by total or segmental non-obstructive colonic dilatation of at least 6 cm associated with systemic toxicity. Methods: Overall, 15 patients had surgery for TM at our institutions over a 10-year period (1993–2003). In contrast to other studies that used medical therapy as the first-line treatment for TM, in our experience all patients underwent surgery as soon as possible after diagnosis of TM (early surgery). Results: 14 patients underwent subtotal colectomy with terminal ileostomy, while for 1 patient the surgical procedure consisted only in a decompressive cecostomy. Two major complications occurred consisting of 2 cases of multiple organ failure leading to death. No other major complications or deaths were reported. The overall mortality rate was therefore 13% (0% in patients <65 years). Conclusion: This study shows that early surgery has the potential to represent a valid therapeutic strategy for patients with TM resulting in a small number of TM-related complications and deaths. Elderly patients seem to have a high risk of multiple organ dysfunction syndrome and post-surgical death.

Acute hepatic failure in pregnancy

Severe liver dysfunction in late pregnancy is an unusual but dramatic event because it can progress very rapidly to fulminating disease and also because two lives, that of the mother and foetus, are involved. We report a descriptive study of a pregnant woman presenting with severe liver dysfunction.