Gilberto Poggioli

Prevalence and effectiveness of psychiatric treatments for patients with IBD: A systematic literature review

OBJECTIVESnHigher prevalence of psychiatric disorders, such as anxiety and depression, has been found in people with Crohns disease and Ulcerative Colitis compared to the general population. Nowadays, international guidelines advocate psychotherapy and psycho-pharmacological treatments as playing an important role in IBD care. The main goal of this systematic literature review was summarize the evidence on the utilization and effectiveness of treatments for depression and anxiety in persons with IBD.nnnMETHODSnA systematic literature review was conducted using three different electronic databases: MEDLINE, PsychINFO, and EMBASE to identify studies reporting the prevalence and efficacy of psycho-pharmacological and psychotherapeutic treatments for IBD. A quality appraisal was conducted using several scales as appropriate for each study design. A narrative synthesis was also performed.nnnRESULTSnForty-three studies were included. Although a high rate of psychoactive drug use was found in people with IBD, a low proportion of IBD patients have access to psychiatric referral. 1/3 of the studies found that psychotherapy was effective for improving the quality of life, perception of stress, anxiety and depression as well as disease. Antidepressants proved effective in reducing disease activity, gastrointestinal symptoms, anxiety and depression.nnnCONCLUSIONnOur results suggest that psychiatric treatment should be implemented in IBD care. However, further studies are needed to confirm the findings of our systematic review.

Prepouch Ileitis After Ileal Pouch-anal Anastomosis: Patterns of Presentation and Risk Factors for Failure of Treatment

Background and AimsnThere is a lack in the literature about prepouch ileitis [PI], in particular regarding risk factors associated with failure of the medical treatment. Aim of the study is to analyse the characteristics of PI patients and to compare those who required surgery with those who were successfully treated with conservative therapy.nnnMethodsnAll cases presenting a diagnosis of PI were included and analysed. Patients eventually requiring surgery were compared with those who were managed conservatively, for symptoms of presentation, endoscopic characteristics, and rate of response to medical treatment. A sub-analysis of outcomes based on the final histology was performed.nnnResultsnThe overall incidence of PI among 1286 patients was 4.4% [57], after a median of 6.8 years from pouch surgery. Symptoms included increased frequency [26.4%], outlet obstruction [21%], and bleeding [15.8%]. Afferent limb stenosis affected 49.1% of patients. The comparison showed that patients requiring surgery had a higher rate of Crohns disease and indeterminate colitis [42.1 vs 0% and 15.8 vs 2.6%, p < 0.0001], outlet obstruction as main symptom [47.4 vs 7.9%, p = 0.0023], and afferent limb stenosis [73.7 vs 36.8%, p = 0.008] at endoscopy. Rate of failure of medical treatment at 5 years was 8.2% in patients with ulcerative colitis and 75% in the presence of both indeterminate colitis and Crohns disease [p < 0.0001].nnnConclusionsnCrohns disease, indeterminate colitis, and stenosis with outlet obstruction are risk factors for failure of treatment after diagnosis of PI. Early aggressive therapy and surgery should be considered in these cases.

Preoperative Chemoradiation With VMAT-SIB in Rectal Cancer: A Phase II Study

Purpose The aim of this study was to investigate the efficacy and toxicity of volumetric modulated arc therapy (VMAT)–simultaneous integrated boost (SIB) in preoperative combined treatment of locally advanced rectal cancer. Methods Radiation therapy was performed using the VMAT‐SIB technique. The dose to mesorectum and pelvic lymph nodes was 45 Gy (1.8 Gy/fraction). A concomitant boost was delivered on GTV + 2‐cm margin with a total dose of 57.5 Gy (2.3 Gy/fraction). The following concomitant chemotherapy was administered: capecitabine (825 mg/m2 twice daily, 5 days per week) and oxaliplatin (130 mg/m2 on days 1, 17, and 35). Efficacy was evaluated in terms of complete pathological response (pCR). Acute toxicities were evaluated according to Common Terminology Criteria for Adverse Events version 3.0 criteria. Results A total of 18 patients (7 women; median age 62 years; clinical stage: 4 local recurrences, 6 cT4, 5 cT3, 3 cT2, 2 cN0, 7 cN1, 9 cN2) were enrolled. Sixteen patients underwent surgical resection (9 low anterior resection, 6 abdominal perineal amputations; 1 transanal excision) and 2 patients did not undergo surgery for early metastatic progression or death from acute pulmonary edema. R0 resection was achieved in all patients who underwent surgery. Overall, 4 patients had a pCR and 7 patients only a microscopic residual of disease (pT0‐Tmic: 11/18 = 61.1%; 95% CI, 36.2‐86.1). Acute grade ≥ 3 toxicity was as follows: 1 case of leukopenia, 1 skin toxicity, 1 genitourinary toxicity, and 5 gastrointestinal toxicities, with an overall incidence of 8 (44.4%) of 18 patients. One‐, 3‐, and 5‐year cumulative local control was 100%, 68.6%, and 68.6%, respectively. One‐, 3‐, and 5‐year cumulative disease‐free survival was 88.9%, 66.7%, and 66.7%, respectively. One‐, 3‐, and 5‐year cumulative overall survival was 85%, 63.8%, and 63.8%, respectively. Conclusion The regimen used in this study showed excellent results in terms of pathologic responses. However, despite the use of the VMAT technique, more than one‐third of patients had severe acute toxicity. Micro‐Abstract The efficacy and toxicity of volumetric modulated arc therapy (VMAT)–simultaneous integrated boost (SIB) in preoperative combined treatment of locally advanced rectal cancer were investigated. VMAT‐SIB with concomitant capecitabine and oxaliplatin showed a good efficacy: 11 (61.1%) of 18 patients had complete or near complete response. Severe acute toxicity was not negligible and reported in 44.4% patients.

Endoluminal vacuum-assisted therapy as treatment for anastomotic leak after ileal pouch–anal anastomosis: a pilot study

AbstractBackgroundAnastomotic leak after ileal pouch–anal anastomosis (IPAA) could lead to poor functional results and failure of the pouch. The aim of the present study was to analyze the outcomes of the vacuum-assisted closure therapy as the unique treatment for anastomotic leaks following IPAA without any additional surgical operations.nMethodsConsecutive patients with anastomotic leak after IPAA treated at our institution between March 2016 and March 2017 were prospectively enrolled. After diagnosis, the Endosponge® device was positioned in the gap and replaced until the cavity was reduced in size and covered by granulating tissue. A pouchoscopy was performed every week for the first month and monthly subsequently. No additional procedures were performed.ResultsEight patients were included in the study. The leak was diagnosed at a median of 14 (6–35) days after surgery. At the time of diagnosis, seven patients had a defunctioning ileostomy performed as routine at the time of pouch formation, while one patient was diagnosed after ileostomy closure and underwent emergency diversion ileostomy. The Endosponge® treatment started after a median of 6.5 (1–158) days after the diagnosis of the leakage and was carried on for a median of 12 (3–42) days. The device was replaced a median of 3 (1–10) times. The median length of hospital stay after the first application of the treatment was 15.5 (6–48) days. The complete healing of the leak was documented in all patients, after a median of 60 (24–90) days from the first treatment. All patients but one had their ileostomy reversed at a median of 2.5 (1–6) months from the confirmation of the complete closure.ConclusionsEndosponge® is effective as the only treatment after IPAA leak. Based on the results of our prospective pilot study, application of Endosponge® should be the treatment of choice in selected pouch anastomotic leaks not requiring immediate surgery. These results will have to be confirmed by future prospective studies including a larger number of patients.

Mucosa-associated microbiota dysbiosis in colitis associated cancer.

ABSTRACT Gut microbiota dysbiosis has been associated with inflammatory bowel diseases (IBD). In colorectal cancer, the gut microbiota has also been recognized as potentially involved in aggravating or favoring the tumor development. However, very little is known on the structure and role of the microbiota in colitis associated cancer (CAC), an important complication of IBD in human. Here we analyzed the bacterial and fungal composition of the mucosa associated microbiota of patients suffering CAC, sporadic cancer (SC) and of healthy subjects (HS) by barcode sequences analysis on the following cohort: 7 CAC patients, 10 SC patients and 10 HS using 16S (MiSeq) and ITS2 (pyrosequencing) sequencing, for bacteria and fungi respectively. Mucosa-associated bacterial microbiota in CAC was significantly different from the ones in SC or in HS, while the fungal showed no differences. Comparison between mucosa-associated microbiota on the tumor site or in normal mucosa near the tumor showed very similar patterns. The global mucosa-associated bacterial microbiota in cancer patients was characterized by a restriction in biodiversity but no change for the fungal community. Compared to SC, CAC was characterized by an increase of Enterobacteriacae family and Sphingomonas genus and a decrease of Fusobacterium and Ruminococcus genus. Our study confirms the alteration of the mucosa-associated bacterial microbiota in IBD and SC. Although the cohort is limited in number, this is the first evidence of the existence of an altered bacterial microbiota in CAC clearly different from the one in SC patients.

Real-time elastography for the detection of fibrotic and inflammatory tissue in patients with stricturing Crohn’s disease

PurposeThe distinction between active inflammation and fibrosis of the bowel wall is essential for therapeutic decisions in stricturing Crohn’s disease. We aimed to assess whether real-time elastography (RTE) with strain ratio measurement could be useful in differentiating fibrotic from inflamed bowel strictures and to evaluate the possible relationship between US techniques and the histology of the stenotic bowel wall.Materials and methodsBowel ultrasonography (including RTE, color-Doppler and CEUS examination) was prospectively evaluated in 26 patients with symptomatic stricturing Crohn’s disease, before surgery. RTE was adopted to evaluate bowel stiffness: five loops of 20 RTE frames were recorded for each stenotic segment and the mean strain ratio (MSR) was obtained. Histology scoring systems both for inflammation and fibrosis were established for surgical specimens.ResultsNo significant correlation was found between MSR and fibrosis score (Pxa0=xa00.877). Color-Doppler score was significantly related to gut wall and submucosal thicknesses (Pxa0=xa00.006 and Pxa0=xa00.032, respectively). There was no significant correlation between the number of vessels counted at histology and color-Doppler and CEUS examinations (Pxa0=xa00.170 and Pxa0=xa00.302, respectively).ConclusionMSR detection was not able to distinguish fibrotic from inflammatory tissue in our selected population. This result could be influenced by the presence of the superimposed inflammation. Larger cohort of patients, further analysis with shear wave elastography, and validated histopathology classification systems for fibrosis and inflammation are necessary to assess if intestinal fibrosis could be reliably detected on the basis of bowel elastic properties.SommarioObiettivola distinzione tra infiammazione attiva e fibrosi nella parete intestinale è essenziale nel proceso decisionale della terapia nella malattia di Crohn stenosante. Lo scopo del nostro studio era di stabilire se l’elastografia real-time (RTE) con la misurazione dello strain ratio potesse essere utile nel differenziare il tessuto fibrotico da quello infiammatorio nella parete intestinale stenotica, e di valutare la presenza di correlazioni tra le tecniche ecografiche di studio delle anse intestinali e le caratteristiche istologiche dei segmenti analizzati.Materiali e metodiLo studio ecografico delle anse intestinali che comprendeva anche RTE, valutazione color-Doppler e CEUS, è stato eseguito in maniera prospettica in 26 pazienti con malattia di Crohn stenosante sintomatica, prima dell’ intervento chirurgico resettivo. La RTE è stata utilizzata per valutare la rigidità della parete intestinale: 5 filmati di 20 frames di elastografia sono stati registrati per ogni segmento stenotico, per ogni frame è stato calcolato lo strain ratio e quindi ne è stata ottenuta la media (MSR). E’ stato poi stabilito uno score istologico per l’ infiammazione e la fibrosi per i pezzi operatori analizzati.Risultatinon è stata rilevata alcuna correlazione significativa tra MSR e score istologico della fibrosi (Pxa0=xa00877). Il Color-doppler correlava significativamente con lo spessore di parete e l’ispessimento della sottomucosa (Pxa0=xa00006 e Pxa0=xa00032, rispettivamente). Non è stata trovata una correlazione significativa tra il numero di vasi rilevato sul pezzo istologico e gli score color-Doppler e CEUS (Pxa0=xa00170 e Pxa0=xa00302, rispettivamente).Conclusioniil calcolo del MSR non si è rivelato un parametro efficace nel distinguere tra tessuto fibrotico ed infiammatorio nella nostra popolazione. Questo risultato è influenzato da vari fattori, tra cui probabilmente la compresenza di infiammazione. Coorti di pazienti più ampie, ulteriori analisi con l’ausilio eventualmente dell’ elastografia shear-wave, e sistemi di classificazione istopatologici validati sia per la fibrosi che per l’infiammazione, risultano necessari per stabilire se la fibrosi intestinale possa essere rilevata in maniera affidabile sulla base delle proprietà elastiche della parete intestinale.

Transabdominal salvage surgery after pouch failure in a tertiary center: A case-matched study ☆

BACKGROUNDnSalvage surgery after failure of ileal pouch-anal anastomosis (IPAA) could be offered to selected patients. However, the results vary widely in different centers.nnnAIMSnTo assess the outcomes of salvage surgery by comparison with a control group matched for confounding variables.nnnMETHODSnFrom a prospective database of 1286 IPAA, patients undergoing transabdominal salvage surgery were compared for perioperative and functional outcomes and quality of life (QOL) to a 1:3 control group of primary IPAA cases.nnnRESULTSnSalvage surgery patients (30) had a higher rate of hand-sewn anastomoses (80 vs 20%, p <0.0001) and reoperations (10 vs 2.2%, p 0.02) than control group (90). A higher number of daytime and nighttime bowel movements (7.4 vs 4.1, p <0.0001, and 2.6 vs 1.8, p=0.002), a lower median CGQL score (0.7 vs 0.8, p=0.0001) and a higher rate of pouch fistulae (13.3 vs 1.1%, p=0.003) were reported after salvage surgery. Pouch failure rate after salvage surgery was 10.1%, 18.7% and 26.8% at 1, 5 and 10 years (vs 0%, 3.5% and 8.4% in control group, p=0.0085).nnnCONCLUSIONSnAlthough worse functional outcomes and decreased QOL have to be expected, salvage surgery after pouch failure is associated with acceptable outcomes when performed in a referral center.

Gracilis muscle transposition for the treatment of recurrent rectovaginal and pouch-vaginal fistula: is Crohn’s disease a risk factor for failure? A prospective cohort study

BackgroundThe surgical management of rectovaginal fistulae associated with Crohn’s disease is often frustrated by poor results regardless of the different techniques. The outcomes of the gracilis muscle transposition (GMT) for the treatment of recurrent Crohn’s-associated fistulae are still debated. The aim of the study is to determine whether the success rate of GMT is similar in Crohn’s disease patients and in a control group.Materials and methodsAll patients undergoing GMT for rectovaginal or pouch-vaginal fistula were collected from a prospectively maintained database (2005–2016). The primary study outcome was the comparison of the success rate of GMT in Crohn’s disease and control group patients.ResultsTwenty-one patients with a rectovaginal fistula due to Crohn’s disease (8, 38.1%) or other etiologies (13, 61.9%) were included. The groups had similar characteristics and postoperative outcomes. After a median follow-up time of 81 and 57xa0months (p 0.34), the success rate of GMT was 75% in patients with Crohn’s disease and 68.4% in control group (p 0.6). The median time to recurrence was 3.5xa0months (1–12). The success rate in patients who had more than two previous attempts of repair was lower regardless of the etiology (50 vs 79.4%, p 0.1).ConclusionGMT is associated with a high success rate, especially in Crohn’s disease-related rectovaginal fistula. In consideration of the low morbidity rate and the fact that an increasing number of previous local operations might be associated with failure, the procedure should be considered as a first line of treatment for recurrent rectovaginal fistulae.

Outcomes of pelvic exenteration for recurrent and primary locally advanced rectal cancer

BACKGROUNDnPelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably reported in the literature, with recent series suggesting similar survival between ARC and RRC. The study aimed to analyze and compare the long-term survival and perioperative outcomes of patients undergoing pelvic exenteration for ARC and RRC in a tertiary center.nnnMATERIALS AND METHODSnThis was a retrospective analysis of prospectively collected data. Comparison of variables was performed using Chi-square, Fishers exact or Wilcoxon rank sum test as appropriate. The Kaplan Meier method was used to analyze the disease-free survival (DFS) and the log-rank test to compare the two groups.nnnRESULTSnSince 2002, 46 patients underwent pelvic exenteration for ARC (28, 60.9%) and RRC (18, 39.1%). The groups had comparable characteristics, perioperative results, including postoperative complications, and rate of adjuvant chemotherapy. A R0 resection was obtained in 71.4% and 55.6% (p 0.41) and a T4 stage was diagnosed in 75% and 94.4% (p 0.22) of ARC and RRC patients, respectively. After a median follow-up time of 32.5 and 56.6 months (p 0.01), the 5-year DFS was significantly lower in the RRC group (23.6 vs 46.2%, p 0.006), even after exclusion of R1 cases (30 vs 54.5%, p 0.044).nnnCONCLUSIONnThe long-term disease free survival of patients undergoing pelvic exenteration is significantly worse when the procedure is performed for RRC, regardless of the tumor involvement of the resection margins.