Nicola de'Angelis

Elucidating the gut microbiome of ulcerative colitis: bifidobacteria as novel microbial biomarkers

Ulcerative colitis (UC) is associated with a substantial alteration of specific gut commensals, some of which may be involved in microbiota-mediated protection. In this study, microbiota cataloging of UC patients by 16S rRNA microbial profiling revealed a marked reduction of bifidobacteria, in particular the Bifidobacterium bifidum species, thus suggesting that this taxon plays a biological role in the aetiology of UC. We investigated this further through an in vivo trial by testing the effects of oral treatment with B. bifidum PRL2010 in a wild-type murine colitis model. TNBS-treated mice receiving 10(9) cells of B. bifidum PRL2010 showed a marked reduction of all colitis-associated histological indices as well as maintenance of mucosal integrity as it was shown by the increase in the expression of many tight junction-encoding genes. The protective role of B. bifidum PRL2010, as well as its sortase-dependent pili, appears to be established through the induction of an innate immune response of the host. These results highlight the importance of B. bifidum as a microbial biomarker for UC, revealing its role in protection against experimentally induced colitis.

Open and laparoscopic resection of hepatocellular adenoma: trends over 23 years at a specialist hepatobiliary unit

BACKGROUND Hepatocellular adenoma (HCA) is a rare benign liver epithelial tumour that can require surgery. This retrospective study reports a 23-year experience of open and laparoscopic resections for HCA. METHODS Patients with a histological diagnosis of HCA were included in this analysis. Surgical resection was performed in all symptomatic patients and in those with lesions measuring >5 cm. RESULTS Between 1989 and 2012, 62 patients, 59 of whom were female, underwent surgery for HCA (26 by open surgery and 36 by laparoscopic surgery). Overall, 96.6% of female patients had a history of contraceptive use; 54.8% of patients presented with abdominal pain and 11.2% with haemorrhage; the remaining patients were asymptomatic. Patients who underwent laparoscopy had smaller lesions (mean ± standard deviation diameter: 68.3 ± 35.2 mm versus 91.9 ± 42.5 mm; P = 0.022). Operatively, laparoscopic and open liver resection did not differ except in the number of pedicle clamps, which was significantly lower in the laparoscopic group (27.8% versus 57.7% of patients; P = 0.008). Postoperative variables did not differ between the groups. Mortality was nil. Two surgical specimens were classified as HCA/borderline hepatocellular carcinoma. At the 3-year follow-up, all patients were alive with no recurrence of HCA. CONCLUSIONS Open and laparoscopic liver resections are both safe and feasible approaches for the surgical management of HCA. However, laparoscopic liver resections may be limited by lesion size and location and require advanced surgical skills.

Confocal Laser Endomicroscopy in Gastrointestinal and Pancreatobiliary Diseases: A Systematic Review and Meta-Analysis

Confocal laser endomicroscopy (CLE) is an endoscopic-assisted technique developed to obtain histopathological diagnoses of gastrointestinal and pancreatobiliary diseases in real time. The objective of this systematic review is to analyze the current literature on CLE and to evaluate the applicability and diagnostic yield of CLE in patients with gastrointestinal and pancreatobiliary diseases. A literature search was performed on MEDLINE, EMBASE, Scopus, and Cochrane Oral Health Group Specialized Register, using pertinent keywords without time limitations. Both prospective and retrospective clinical studies that evaluated the sensitivity, specificity, or accuracy of CLE were eligible for inclusion. Of 662 articles identified, 102 studies were included in the systematic review. The studies were conducted between 2004 and 2015 in 16 different countries. CLE demonstrated high sensitivity and specificity in the detection of dysplasia in Barretts esophagus, gastric neoplasms and polyps, colorectal cancers in inflammatory bowel disease, malignant pancreatobiliary strictures, and pancreatic cysts. Although CLE has several promising applications, its use has been limited by its low availability, high cost, and need of specific operator training. Further clinical trials with a particular focus on cost-effectiveness and medicoeconomic analyses, as well as standardized institutional training, are advocated to implement CLE in routine clinical practice.

A simple technique for procuring liver allografts while protecting arterial vessels

Arterial injury remains a common complication during organ procurement, with negative effects on postoperative morbidity and graft survival. We describe a simple technique that helps surgeons avoid vascular injuries during isolated liver procurement (without pancreas). This simple technique has been used in 200 liver procurements without any arterial injuries.

The open abdomen in trauma and non-trauma patients: WSES guidelines

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a “planned second-look” laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

Clinical Outcomes of Right-Lobe Split-Liver versus Orthotopic Liver Transplants from Donors More than 70 Years Old

Context— The imbalance between the organ supply and the number of potential transplant recipients led to consideration of expanded-criteria liver donors. Objective— To compare right-lobe split-liver transplants (RL-SLTs) with orthotopic liver transplants (OLTs) from donors more than 70 years old (OLT-O) and OLTs from donors less than 55 years old (OLT-Y). Methods— Seventy-one patients who received an RL-SLT were matched for age, sex, and Model for End-stage Liver Disease score with 71 patients who underwent OLT-O and 142 patients who underwent OLT-Y. Clinical outcomes were compared between groups. Results— Longer operation time was associated with RL-SLT (P < .001) as well as more blood loss (P = .03) and transfusions (P = .05). Postoperative morbidity was less in the OLT-Y group, with a lower rate of grades III to IV Clavien-Dindo complication (30%), compared with values in OLT-O (52%) and RL-SLT (38%). Kaplan-Meier analysis demonstrated better 1-year and 3-year survival rates in the OLT-Y group (97% and 92%, respectively), compared with 92% and 86.3%, respectively, in the RL-SLT group; and 84.5% and 73%, respectively, in the OLT-O group (P = .03). Kaplan-Meier analysis also demonstrated differences between the groups in terms of 1-year and 3-year graft survival rates, which were 92% and 86%, respectively, in OLT-Y; 77% and 66%, respectively, in the OLT-O, and 84.2% and 76.6%, respectively, in the RL-SLT group (P = .01). Conclusion— Even if OLT-Y guarantees better patient and graft survival, both RL-SLT and OLT-O can be used safely to expand the pool of liver donors, showing acceptable clinical results and complications rates.

Gluten peptides drive healthy and celiac monocytes toward an M2-like polarization

Celiac disease (CD) is an immune-mediated enteropathy triggered by ingested gluten in genetically susceptible individuals and sustained by both adaptive and innate immune responses. Recent studies in murine macrophages demonstrated that the activation of arginase (ARG) metabolic pathway by gluten peptides contributes to the modulation of intestinal permeability in vitro. Here we characterize the effects of gluten on arginine metabolism and cell polarization in human monocytes from both healthy and CD subjects; both a simplified enzymatic digestion of gliadin and a physiological digestion of whole wheat have been tested. Results indicate that gluten digests induce the onset of an M2-like phenotype in activated macrophages; more precisely, both isoforms of arginase, ARG1 and ARG2, are induced likely due to the inhibition of mTOR and the consequent induction of C/EBPβ transcription factor. These effects are independent from the origin of gluten as well as from the digestive protocol employed; moreover, no statistical difference can be evidenced between healthy and CD patients, excluding a diverse predisposition of CD monocytes to gluten-triggered polarization with respect to healthy immune cells. Overall, the present findings sustain a role for arginase pathway in the immune response elicited by human monocytes toward ingested gluten that, hence, deserves particular attention when addressing the pathogenesis of CD.

Personal Experience With 150 Isolated Procurements of Liver Allografts: Two Different Techniques.

Procurements of Liver Allografts: Two Different Techniques This letter describes 2 different techniques based on the experience of one surgeon on 150 liver transplant donors. The first 90 procurements were performed with the en bloc technique (EBT), and the last 60 cases with a selective in vivo normothermic dissection (SIDT; see Figure). Operative technique: The beginning of the procurement is the same with both techniques, a midline incision from the xiphoid process to the symphysis pubis and a transverse incision. In cases of simultaneous cardiac and/or pulmonary procurement, the transverse incision can be extended to the suprasternal notch. After a detailed exploration of the abdominal cavity, the inferior mesenteric vein, inferior vena cava (IVC), and aorta are dissected and prepared for portal and aortic perfusion. A horizontal incision is performed on the diaphragm to allow access to the thoracic IVC. After dividing the bile duct at its pancreatic portion, the gallbladder is dissected and the lumen of the bile duct is irrigated with saline solution to prevent autolysis of the bile duct mucosae. The supraceliac abdominal aorta is dissected at the last moment of the warm phase. Clamping of the IVC in its infrarenal and thoracic portion is followed by aortic and portal hypothermic perfusion associated with topical cooling with crushed ice. EBT: No further dissection is performed in the warm phase. The dissection in the cold phase begins with a cut through the pancreatic parenchyma, splenic artery, and splenic vein; mobilization of the stomach on the lesser curvature to the cardia; moving the stomach and duodenum in the left hypochondrium; and separation of the duodenum from the pancreas up to the ligament of Treitz. Thus, the superior mesenteric artery (SMA) and vein are transected 10 cm above their origin into the mesentery, as previously described. The hepatectomy is finished with the resection of a large patch of diaphragm and with the liberation of the IVC and aorta from the prevertebral fascia. SIDT: The first part of the procurement during the warm phase involves locating the right/left hepatic artery. The left hepatic artery (LHA) is easy to find in the middle of the pars flaccida, but locating the accessory right hepatic artery is the most dangerous part of this technique. The reason why it is important to locate the right hepatic artery is that, if it is present, the dissection must be done toward the SMA. Thus, procurement is focused on the hepatic pedicle. Arterial dissection begins with the gastroduodenal artery (GDA). The dissection should be performed along the common hepatic artery to the celiac trunk. The splenic artery and left gastric artery (LGA) are also dissected carefully, observing for the presence of the LHA. The second part of the procurement, after clamping and cooling, is very simple. The GDA is divided 2 cm from its origin, allowing easy access to the portal vein. The pancreatic parenchyma is transected between head and body to allow the splenic vein and superior mesenteric vein to be cut. This transection is a big limitation of this technique because it cannot be done if the pancreas is being procured for transplant. The splenic artery and the LGA are divided at a safe distance from the origin of the celiac trunk, which is finally cut at its origin with a large patch. If an accessory right hepatic artery is present, an aortic patch with the origin of SMA is secured. The hepatectomy ends as in EBT. Backtable: An ice basin is covered with a double ileal bag and filled with cold preservation solution, ensuring a hypothermic backtable. In the case of EBT, the procedure starts by positioning the liver with its caval face up. The superior mesenteric vein and the splenic vein are identified and dissected until the left and right bifurcation of the portal vein is reached. After this, the aortic patch is dissected, starting from the SMA and the absence of an accessory right hepatic artery is verified. Thereafter, the celiac trunk is identified and the splenic artery and LGA are completely liberated. Dissection continues up the hepatic artery to the origin of the GDA. No further arterial dissection is necessary to avoid arterial lesion; in the case of a LHA, the dissection is continued up to its origin. Cholecystectomy is completed. Retrohepatic location of the IVC is guaranteed by ligation of multiple extrahepat ic caval branches. The cuff path of the diaphragm is removed from the superior portion of the IVC. A final flush with 1000 mL of cold storage perfusion is given via the portal vein. In SIDT, the common hepatic artery is dissected up to the GDA and the liver is perfused via the portal Letters to the Editor

Transformation of cavoportal inflow to renoportal inflow to the graft during liver transplantation for stage IV portal vein thrombosis

A 51-year-old male underwent liver transplantation for end-stage liver disease. A pretransplant scan demonstrated a Yerdel grade IV portal vein thrombus with spontaneous mesentericocaval shunt insertion below the junction of the inferior vena cava (IVC) and the left renal vein (Fig. 1). The caval inflow technique was modified to transform an indication for a cavoportal anastomosis (CPA) into the equivalent of a renoportal anastomosis (RPA).

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO)

BackgroundAdhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups.MethodsThe guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion.RecommendationsAdhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention.DiscussionThis guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.