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Ruolo della chirurgia nell’ occlusione intestinale nei pazienti affetti da malattia di Crohn.
No full textL’occlusione rappresenta la più frequente indicazione all’intervento chirurgico (30-40%), che, ogniqualvolta possibile, va eseguito in elezione o almeno in urgenza differita per ridurre l’incidenza delle complicanze postoperatorie
I pazienti che non rispondono alla terapia conservativa, con segni di sofferenza vascolare o di pericolo di incipiente perforazione, devono essere operati in urgenza. Un intervento in elezione trova giustificazione nei casi di ostruzione persistente nonostante una adeguata terapia medica, specialmente se si tratta di una stenosi di vecchia data con prevalente componente fibrotica.
In fase preoperatoria è utile un approfondimento diagnostico clinico, laboratoristico e strumentale. La TC e la RM consentono di escludere ascessi concomitanti, di precisare la localizzazione e l’estensione e di definire il grado di attività della malattia (lieve, moderata, severa); in caso di assenza di importanti segni di flogosi (> calprotectina, > vascolarizzazione e contrast enhancement) la chirurgia precoce è valida alternativa alla terapia medica.
Nei pazienti destinati alla chirurgia precoce è importante valutare la terapia in atto prima dell’evento occlusivo; gli steroidi > il rischio di complicanze postoperatorie e pertanto vanno scalati. I biologici, peraltro indicati quale terapia conservativa nei pazienti non destinati alla chirurgia immediata, determinerebbero un incremento delle complicanze postoperatorie (ma non delle infezioni).
L’intervento di scelta è la resezione. La ricostruzione del transito è di frequente protetta da una ileostomia. La concomitanza di un ascesso impone il drenaggio chirurgico o, preferibilmente, TC-guidato in fase di studio e di preparazione preoperatoria. Una stenosi, se raggiungibile dall’endoscopio, può essere trattata in maniera conservativa (dilatazione, endoprotesi).
L’anastomosi meccanica L-L a lume ampio è la migliore, poiché presenta bassi tassi di complicanze e forse di RPO, se confrontata con quella manuale.
Questo caso (paz giovane, plurioperata) illustra l’importanza di risparmiare quanto più possibile un intestino già resecato: è stato conservato l’ileo terminale, sede di riassorbimento attivo di Vit B 12 e di sali biliari, per evitare il conclamarsi della SBS. Attenzione è stata posta per evitare cul di sacchi, che, con la conseguente iperproliferazione batterica, aggraverebbero la SBS.
Le stricturoplastiche (Mikuliks, Finney, Taschieri, Fazio) sono riservate a pochi casi selezionati con stenosi del piccolo intestino
Surgical timing in the management of Crohn's disease in the era of biological drugs.
No full textBackground The indications and the timing for surgery are obviously related to the type of complications; but a key role, in choosing the most appropriate time to perform surgery, is played not only by factors related to patient but also by the evaluation of disease intrinsic characteristics:
stenosing/penetrating/inflammatory disease, disease activity, extension, prevalent localization and the response to medical therapy. Methods The authors analyzed the literature of the past two decades by integrating it with their personal experience. The authors have paid attention above all to Crohn’s disease management. Results Advances in medical therapy over the past two decades have substantially altered the management of patients with IBD. The introduction of more aggressive regimens (top down strategy) resulted in a change of surgery, which is no longer seen as “a last resort”, to be reserved for the treatment of a longstanding disease with more serious complications, but should also be seen as “early surgery”, able to induce remissions faster and perhaps more durable, at least in the short to medium term. It is logical to wonder whether this is also a result of a change in the natural history of the disease under the influence of new therapies. Biological drugs have proved to be able to induce remission (60%), to keep it free from steroids for short-medium periods and to return the integrity of the mucosa, which is important to control the disease. Mucosal healing leads to a decrease of complications’ rate, fewer hospitalizations and thus a possible reduction in the rate of surgical interventions. There are
still doubts about the real reduction of the need for surgery. Biological drugs have positive response only in 60% of cases and it is also possible to develop antibody reactions and resistance to the drug (10%). In addition, the disease often presents as a stenosing form, for which biologics are little or no effective and so surgery, even early, is required. Prolonged periods of remission are achieved only in 15% of cases. Borrowing the positive effects of antiTNF in the treatment of rheumatic diseases, we wondered if the use of biologics in Crohn’s disease may result in a change of the natural history of the disease. This problem remains unsolved. Doubts also remain about the actual reduction in the rate of hospitalization and in the need for surgery. Conflicting data emerge from randomized trials and observational studies. Conclusions There is still no evidence of a real reduction in the rate of interventions. Even today, the ideal treatment of Crohn’s disease is an unclear argument. Surgery plays a leading role and should not be considered only as “a last resort”; early surgery may indeed allow faster and more lasting remission
Infections in patients with inflammatory bowel disease
No full textBackground/aim: Inflammatory bowel diseases (IBD) are a group of conditions characterized by chronic inflammation of all or part of the digestive tract and primarily includes Ulcerative Colitis (UC) and Crohn's Disease (CD). This review has as target to summarize the complicated correlation between IBD and infections, which can affect patients' quality of life and increase substantially morbidity and mortality rates.
Results: Scientific evidence in recent years shows a growing recognition of the phenomenon although the association between these two aspects is not definitively clear. Despite the fact that our understanding of this linkage is still incomplete, it is easily deducible that infections can start whether it be the onset or the relapse of IBD. In addition to this, the course of the disease predisposes the patient to numerous infections caused by the drugs used to treat IBD and this also raises the risk of infection complications.
Conclusions: Clinical trials have demonstrated that the combined use of immunomodulating agents may increase the risk of new infections. The infections might be intensified by an insufficient vaccination of adults with IBD. Physicians have to be aware of these risks and try to attenuate and treat them properly
Sleeve gastrectomy may double the risk of esophageal adenocarcinoma in morbidly obese patients
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Management of occlusive Crohn's disease
No full textBackground In Crohn's disease occlusion has become the most frequent indication for surgery (30-40%). Methods The authors analyzed the literature of the last two decades by integrating it with their series. Results Patients not responding to conservative therapy, with signs of vascular or impending perforation, should undergo surgery in urgency. An elective surgical procedure is instead possible in cases of persistent obstruction, despite an adequate medical therapy, especially if it is longstanding stenosis with relevant fibrotic component. Preoperatively it is useful a clinical, laboratory and instrumental depth study. CT and MRI allow to rule out concomitant abscesses, to specify localization and extent and to define the degree of disease activity; in the absence of significant signs of nflammation (increased calprotectin, vascularity and contrastenhancement) early surgery is a valid alternative to medical therapy. It is important to evaluate current treatment before the occlusive event in patients destined to early surgery; in fact steroids increase the risk of postoperative complications and therefore they should be scaled. Biologics, also referred to as conservative therapy in patients not intended for immediate surgery, would lead to an increase in postoperative complications (but not infection). The procedure of choice is resection. If there is a concomitant abscess a surgical drainage is required. Stenosis, if endoscopically reachable, can be treated conservatively. Mechanical wide lumen side-to-side anastomosis is the best one, because it has lower complication rates when compared with hand sewing anastomosis. Strictureplasty is reserved for few selected cases with stenosis of the small intestine. Conclusions In Crohn's disease complicated by occlusion, elective surgery should be performed or at least in deferred urgency in order to reduce the incidence of postoperative complications
Recurrent Leiomyosarcoma of the Small Bowel: A Case Series
No full textLeiomyosarcoma is an extremely rare, small bowel neoplasm (2% of all gastrointestinal tumours). Early diagnosis is challenging due to the slow growth of the cancer. The biological behaviour of this group of tumours is aggressive, and the first-line treatment is surgical resection
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
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