Lino Polese

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.

A randomized study comparing ligation with propranolol for primary prophylaxis of variceal bleeding in candidates for liver transplantation.

Whether beta‐blockers (BB) or banding is the best therapy for primary prophylaxis of variceal bleeding is subject to debate. A randomized comparison between the 2 treatments was performed in candidates for liver transplantation (LT). A total of 62 patients with Child‐Turcotte‐Pugh B‐C cirrhosis and high risk varices received propranolol (31) or variceal banding (31). The primary endpoint was variceal bleeding. There were 2 variceal hemorrhages (6.5%) in the banding group, related to postbanding ulcers, and 3 (9.7%) in the propranolol group (P = not significant [n.s.]). Deaths and bleeding related deaths were 3 and 1 for banding and 3 and 2 for BB, respectively (P = n.s.). A total of 14 patients underwent LT in the banding group and 10 in the propranolol group (P = n.s.). Adverse events were 2 postbanding ulcer bleedings in ligated patients (1 fatal) and 5 were intolerant to propranolol (P = n.s.). Mean costs per patient were higher with banding than with propranolol treatment (4,289 ± 285 vs. 1,425 ± 460 U.S. dollars, P < 0.001). In conclusion, propranolol and banding are similarly effective in reducing the incidence of variceal bleeding in candidates for LT, but ligation can be complicated by fatal bleeding and is more expensive. Our results suggest that banding should not be utilized as primary prophylaxis in transplant candidates who can be treated with BB. Liver Transpl, 2007.

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.

Barrett's esophagus and adenocarcinoma risk: the experience of the North-Eastern Italian Registry (EBRA).

Objective:To establish the incidence and risk factors for progression to high-grade intraepithelial neoplasia (HG-IEN) or Barretts esophageal adenocarcinoma (BAc) in a prospective cohort of patients with esophageal intestinal metaplasia [(BE)]. Background:BE is associated with an increased risk of BAc unless cases are detected early by surveillance. No consistent data are available on the prevalence of BE-related cancer, the ideal surveillance schedule, or the risk factors for cancer. Methods:In 2003, a regional registry of BE patients was created in north-east Italy, establishing the related diagnostic criteria (endoscopic landmarks, biopsy protocol, histological classification) and timing of follow-up (tailored to histology) and recording patient outcomes. Thirteen centers were involved and audited yearly. The probability of progression to HG-IEN/BAc was calculated using the Kaplan-Meier method; the Cox regression model was used to calculate the risk of progression. Results:HG-IEN (10 cases) and EAc (7 cases) detected at the index endoscopy or in the first year of follow-up were considered to be cases of preexisting disease and excluded; 841 patients with at least 2 endoscopies {median, 3 [interquartile range (IQR): 2–4); median follow-up = 44.6 [IQR: 24.7–60.5] months; total 3083 patient-years} formed the study group [male/female = 646/195; median age, 60 (IQR: 51–68) years]. Twenty-two patients progressed to HG-IEN or BAc (incidence: 0.72 per 100 patient-years) after a median of 40.2 (26.9–50.4) months. At multivariate analysis, endoscopic abnormalities, that is, ulceration or nodularity (P = 0.0002; relative risk [RR] = 7.6; 95% confidence interval, 2.63–21.9), LG-IEN (P = 0.02, RR = 3.7; 95% confidence interval, 1.22–11.43), and BE length (P = 0.01; RR = 1.16; 95% confidence interval, 1.03–1.30) were associated with BE progression. Among the LG-IEN patients, the incidence of HG-IEN/EAc was 3.17 patient-years, that is, 6 times higher than in BE patients without LG-IEN. Conclusions:These results suggest that in the absence of intraepithelial neoplastic changes, BE carries a low risk of progression to HG-IEN/BAc, and strict surveillance (or ablative therapy) is advisable in cases with endoscopic abnormalities, LG-IEN or long BE segments.

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.

Risk factors for colorectal anastomotic stenoses and their impact on quality of life: what are the lessons to learn?

Aim  The aim of the study was to analyse the incidence of benign colorectal anastomotic stenoses in consecutive patients operated on in a single institution and to assess risk factors for their development. Their impact on quality of life was also evaluated.

Cytokine network in rectal mucosa in perianal Crohn's disease: Relations with inflammatory parameters and need for surgery†

Background: Nowadays anti‐TNF‐&agr; antibodies are used for the treatment of perianal Crohns disease (CD). Nevertheless, this treatment is effective in only a part of these patients and recent studies suggested a role for other cytokines in chronic bowel inflammation. The aim of this study was to assess the cytokine profile in the rectal mucosa of patients affected by perianal CD and to understand its relations with the systemic cytokine profile and inflammatory parameters and the need for surgery. Methods: Seventeen patients affected by perianal CD, 7 affected by CD without perianal involvement, and 17 healthy controls were enrolled and underwent blood sampling and endoscopy. During endoscopy rectal mucosal samples were taken and the expression of TNF‐&agr;, IL‐6, IL‐1&bgr;, IL‐12, and TGF‐&bgr;1 was quantified with enzyme‐linked immunosorbent assay (ELISA). Local cytokine levels were compared and correlated with diagnosis, therapy, phenotype (fistulizing and stenosing), and disease activity parameters. Results: In the group with perianal CD, rectal mucosal IL‐1&bgr;, IL‐6, and serum IL‐6 and TNF‐&agr; were higher than in patients with small bowel CD and healthy controls. IL‐12 and TGF‐&bgr;1 mucosal levels did not show any differences among the 3 groups. Mucosal IL‐6 significantly correlated with the Perianal Crohns Disease Activity Index and mucosal TNF‐&agr; and IL‐1&bgr;. Mucosal TNF‐&agr; and IL‐1&bgr; showed a direct correlation with the histological grade of disease activity. Conclusions: The cytokines network analysis in perianal CD shows the important involvement of IL‐1&bgr;, IL‐6, and TNF‐&agr;. Furthermore, mucosal levels of IL‐6 and IL‐12 are predictors of recurrence and of need for surgery in perianal CD patients.

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.

Endoscopic dilation of benign esophageal strictures in a surgical unit: a report on 95 cases.

Ninety-five patients were treated by endoscopic dilation without fluoroscopic guidance between 1997 and 2005 for benign esophageal strictures. The etiologies were: anastomotic (38), postfundoplication (13), caustic (14), peptic (11), radiation-induced (10) and others (9). The strictures were classified at every session on a 0 to 4 scale on the basis of the diet and the luminal diameter. Savary-Gillard or Through-the Scope balloon dilators were used depending on the type and the location of the stenosis. A total of 472 dilation sessions were carried out without serious complications. A normal and a semisolid diet were respectively achieved in 75% and 91%. Recurrence of dysphagia was found in 33% and 51% of the patients respectively after 2 months and 1 year. Improvement of dysphagia, the number of sessions, and recurrence were significantly better in the patients with postsurgical stenosis as compared with those affected by caustic, peptic, and radiation-induced strictures.