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Patients with ulcerative colitis (UC) are at risk of developing a colorectal cancer. The aim of this study was to examine our experience in the treatment of ulcerative Colitis Cancer (CC), the role of the ileal pouch-anal anastomosis (IPAA), and the clinical outcome of the operated patients. Data from 417 patients operated on for ulcerative colitis were reviewed. Fifty-two (12%) were found to have carcinoma of the colon (n = 43) or the rectum (n = 9). The indication to surgery, the histopathological type, the cancer stage, the type of surgery, the oncologic outcome, and the functional result of IPAA were examined. The majority of the patients had a mucinous or signet-ring carcinoma. An advanced stage (III or IV) was present in 28% of the patients. Early (stage I or II) CC was found in all except one patient submitted to surgery for high-grade dysplasia, low-grade dysplasia, or refractory colitis. Thirty-nine (75%) of the 52 patients underwent IPAA, 10 patients were treated with a total abdominal proctocolectomy with terminal ileostomy. IPAA was possible in 6/9 rectal CC. Cumulative survival rate 5 and 10 years after surgery was 61% and 53%, respectively. The survival rate was significantly lower for mucinous or signet-ring carcinomas than for other adenocarcinoma. No significant differences of the functional results and quality of life were observed between IPAA patients aged less than or more than 65 years. Failure of the pouch occurred in 5 of 39 (12.8%) patients for cancer of the pouch (2 pts) or for tumoral recurrence at the pelvic or peritoneal level. Early surgery must be considered every time dysplasia is discovered in patients affected by UC. The advanced tumoral stage and the mucous or signet-ring hystotype influence negatively the response to therapy and the survival after surgery. IPAA can be proposed in the majority of the patients with a functional result similar to that of UC patients not affected by CC. Failures of IPAA for peritoneal recurrence or metachronous cancer of the pouch can be observed when CC is advanced, moucinous, localized in the distal rectum, or is associated with primary sclerosing cholangitis.
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Carcinoma , Colitis Ulcerosa , Proctocolectomía Restauradora , Neoplasias del Recto , Anastomosis Quirúrgica/efectos adversos , Carcinoma/cirugía , Colitis Ulcerosa/complicaciones , Colitis Ulcerosa/cirugía , Humanos , Proctocolectomía Restauradora/efectos adversos , Calidad de Vida , Neoplasias del Recto/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Surgical management of Crohn's colitis represents one of the most complex situations in colorectal surgery. Segmental colectomy (SC) and total abdominal colectomy with ileorectal anastomosis (TAC-IRA) are the most common procedures, but there are few available data on their long-term outcome. The aim of the present study was to analyze the long-term outcome of patients who underwent segmental colectomy for Crohn's colitis, with regard to the risk for total abdominal colectomy. METHODS: In this observational, monocentric, retrospective analysis, we analyzed patients who received a segmental colectomy for Crohn's colitis at our institution. The database was updated by asking patients to complete a questionnaire by telephone or at the outpatient clinic. Only patients followed up at our Hospital were included. Patients were followed up by a specialized multidisciplinary team (IBD Unit). The primary endpoint was the interval between segmental colectomy and, when performed, total abdominal colectomy. RESULTS: Between 1973 and 2014, 200 patients underwent segmental colectomy for Crohn's colitis. The median follow-up was 13.5 years (interquartile range [IQR] 7.8-21.5). Overall, 62 patients (31%) had a surgical recurrence, of these, 42 (21%) received total abdominal colectomy. At multivariate analysis, the presence of ≥ 3 sites (HR = 2.47; 95% CI 1.22-5.00; p = 0.018) and perianal disease (HR = 3.23; 95% CI 1.29-8.07; p = 0.006) proved to be risk factors for total abdominal colectomy. CONCLUSIONS: The risk for surgical recurrence after SC for Crohn's colitis is acceptable. We recommend a bowel-sparing policy for the treatment of Crohn's colitis in any case in which the extent of the disease at the moment of surgery makes the conservative approach achievable.
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Colectomía , Colitis/cirugía , Enfermedad de Crohn/cirugía , Adolescente , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: No previous study clearly focuses on laparoscopic technique to perform the second stage surgery (proctectomy with ileal pouch-anal anastomosis [IPAA]) after total colectomy for acute/severe ulcerative colitis (UC). We describe the procedural steps for a simple and rational minimally invasive second stage surgery, reporting intra- and short-term post-operative results. PATIENTS AND METHODS: During the period December 2014-December 2015, 10 consecutive patients (8 males and 2 females) with mean age of 48 years underwent laparoscopic proctectomy and IPAA adopting our novel approach. They were operated 3 months after the previous total colectomy which has been performed, respectively, for acute (three patients) or severe (seven patients) UC. Intraoperative data and post-operative complications, divided as minor and major, were recorded and analysed. A body image questionnaire was administered to all patients to evaluate the cosmetic results of the procedure. RESULTS: Overall mean surgical time was 235 ± 49 min. During the post-operative course, three patients required morphine for >48 h, no patient needed blood transfusion and bowel movements recovery happened as mean during the 2nd day. No early major complications happened. Two patients (20%) developed peri-ileostomic wound infection at the right flank. Only one patient (10%) suffered from ileal-anal anastomotic dehiscence, conservatively treated till resolution. The average length of hospital stay was 8 ± 2 days. The body image questionnaire showed in all patients an extreme satisfaction about the results obtained (mean value = 59/64 points). CONCLUSIONS: Through three standardised surgical steps easily reproducible, we describe an almost scar-less procedure able to optimise the intraoperative time with good post-operative results in terms of complications and cosmesis.
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BACKGROUND AND AIM: Chemoradiotherapy (CRT) is the gold standard treatment for anal cancer, which permits the maintenance of the anal function. However, about 30-40% of patients develop local disease progression, for which surgery represents a good salvage therapy. The aim of this study is to evaluate survival and morbidity rate in patients who undergo salvage surgery in our single institution, with an overview of the literature. METHODS: A retrospective study was carried out on patients who underwent surgical treatment of anal canal cancer after failure of CRT. We evaluated overall survival at 1, 3, and 5 years and postoperative morbidity rate. RESULTS: Twenty patients who underwent radical surgery with abdominoperineal resection were included in the study. The survival rates at 1, 3, and 5 years were 75, 60, and 37.4%; with a disease-free survival of 67, 53, and 35%, respectively. There was no postoperative mortality. The morbidity rate was 35%. CONCLUSION: Surgery represents the recommended therapy for persistent or recurrent anal canal cancer after CRT, with a good survival rate and an acceptable morbidity.
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Neoplasias del Ano/cirugía , Carcinoma de Células Escamosas/cirugía , Complicaciones Posoperatorias/etiología , Terapia Recuperativa , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias del Ano/terapia , Carcinoma de Células Escamosas/terapia , Quimioradioterapia , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia , Insuficiencia del TratamientoRESUMEN
PURPOSE: The jejunum is a relatively uncommon localization of Crohn's disease (CD) compared to the terminal ileum or the large bowel. The type of surgery and the short and long-term results after surgery have not been extensively investigated. A review of patients who underwent surgery for jejunal CD in our center was examined. METHODS: Between 1986 and 2011, 110 patients underwent surgery for jejunal CD. Thirty patients (27.3 %) were surgically treated with resection, 29 patients (26.4 %) with one or more strictureplasties, and 51 patients (46.3 %) with both a resection and one or more strictureplasties. RESULTS: There was no statistical difference in terms of short-term postoperative complications between patients operated with three different options (p = 0.72). Patients were followed up for a period ranging from 2 to 18 years (mean 11 years). During this period, 42 patients had no CD recurrence, 11 patients had medical recurrences only, while 57 patients had surgical recurrences, too. There was no statistical difference in terms of medical and surgical recurrence between the three types of surgical procedures employed (p = 0.24) and between smokers and non-smokers. The recurrent CD was prevalently treated with strictureplasty. CONCLUSIONS: The most frequently employed surgery for the treatment of jejunal CD is a combined type of treatment, i.e., resection of the most affected tract and strictureplasty of the residual strictures. This approach does not imply an increased risk of postoperative complications and recurrence and can reduce the risk of the short bowel syndrome.
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Enfermedad de Crohn/terapia , Enfermedades del Yeyuno/terapia , Complicaciones Posoperatorias/etiología , Adolescente , Adulto , Anciano , Terapia Combinada , Enfermedad de Crohn/patología , Femenino , Humanos , Enfermedades del Yeyuno/patología , Masculino , Persona de Mediana Edad , Selección de Paciente , Recurrencia , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
Purpose. To evaluate ileorectal anastomosis (IRA) in selected ulcerative colitis patients. Methods. Early and late complications after IRA and IPAA were investigated. Bowel function and quality of life were assessed. Functional and QoL studies were performed as a matched pair analysis, comparing 98 patients who underwent IRA versus 98 patients who underwent IPAA. Results. In IRA group, 2 patients (1.6%) developed anastomotic l dysplasia (HGD) developed in 3 patients dysplasia (HGD) developed in 3 patients eakage, 1 patient (0.8%) had intestinal obstruction, and 2 patients (1.6%) had abdominal hematoma. Mean follow-up was 11.5 (range: 2-24.3) years. Failure of IRA occurred in 19 patients (15.1%); in 12 patients (9.5%), failure was related to severe proctitis, in 3 patients (2.4%), it was related to the development of high-grade dysplasia, and in 4 patients (3.2%), it was related to the development of rectal cancer. About functional results, stool consistency [liquid (6.7% of IRA patients versus 29% of IPAA patients; p = 0.003)], daily soiling (0% versus 6%; p = 0.01), and nocturnal soiling (6% versus 25.5%; p = 0.03) were statistically different. Only 1% of IRA patients versus 11% of IPAA patients had episodes of perianal inflammation (p = 0.007). CGQoL was 0.72 (±0.14, SD) in IRA patients and 0.75 (±0.11, SD) in IPAA patients (p = ns). Conclusion. In selected patients, IRA is an appropriate surgical option, with low morbidity, comparable quality of life, and better functional results than IPAA.
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BACKGROUND: No previous study describes the postoperative outcome and functional results after ileal pouch-anal anastomosis (IPAA), performed in ulcerative colitis by the same surgical team with the different anastomotic techniques adopted in a 27-year period. METHODS: Prospectively, consecutive 333 ulcerative colitis patients operated adopting different IPAA techniques during the open surgery period 1984-2011 were enrolled. IPAA was performed using single stapling (SS) technique in 38 patients, double stapling (DS) technique in 235 patients (TIA stapler 42 patients, Endo-GIA 131 patients, Contour 62 patients) and handsewn IPAA in 60 patients. RESULTS: Statistically different early and late complications were recorded among the different IPAA techniques. A lower frequency of daily and nocturnal defecations and a higher level of continence were observed in the DS-IPAA compared to handsewn IPAA. The distance between the anastomotic line and the anal verge was significantly lower in DS Endo-GIA or DS Contour groups than in the DS TIA and SS. In SS IPAA group, 31.6% developed cuffitis compared to 14.4% belonging to DS group, at a mean follow-up of 140.4 months. CONCLUSIONS: Technical improvements changed the IPAA technique. Stapled IPAA is characterized by better functional outcome than handsewn IPAA. DS Endo-GIA and Contour IPAA are followed by lower risk of cuffitis.
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Colitis Ulcerosa/cirugía , Proctocolectomía Restauradora , Adolescente , Adulto , Anciano , Colitis Ulcerosa/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Proctocolectomía Restauradora/métodos , Estudios Prospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: A temporary stoma is often created to protect a distal anastomosis in colorectal surgery. Short-chain fatty acids, mainly butyrate, are the major fuel source for the epithelium and their absence in the diverted tract may produce mucosal atrophy and inflammation. AIMS: To investigate whether the administration of sodium butyrate enemas (Naburen(©), Promefarm, Italy) could prevent mucosal inflammation and atrophy and affect gene expression profiles after ileo/colostomy. METHODS: We performed a randomized, double-blind, placebo-controlled clinical trial, in patients with enterostomy performed for inflammatory bowel disease, colorectal cancer or diverticulitis. Twenty patients were randomly allocated to receive 30ml of sodium butyrate 600mmol/L (group A) or saline (group B), b.i.d. for 30 days. RESULTS: In group A endoscopic scores were significantly improved (p<0.01) while mucosal atrophy was reduced or unchanged; in group B mucosal atrophy was increased in 42.8% of patients. Despite the high dose of butyrate used, no short-chain fatty acids were detectable by gas chromatography-mass spectrometry in colorectal biopsies. Group A patients showed up-regulation of genes associated with mucosal repair such as Wnt signalling, cytoskeleton regulation and bone morphogenetic protein-antagonists. CONCLUSION: Butyrate enemas may prevent the atrophy of the diverted colon/rectum, thus improving the recovery of tissue integrity.
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Ácido Butírico/farmacología , Fármacos Gastrointestinales/farmacología , Expresión Génica/efectos de los fármacos , Mucosa Intestinal/efectos de los fármacos , Mucosa Intestinal/patología , Proteínas Adaptadoras Transductoras de Señales , Adulto , Anciano , Atrofia/etiología , Atrofia/patología , Atrofia/prevención & control , Ácido Butírico/administración & dosificación , Colitis/etiología , Colitis/patología , Colitis/prevención & control , Colon/efectos de los fármacos , Colon/patología , Colonoscopía , Colostomía/efectos adversos , Citocinas , Método Doble Ciego , Enema , Ácidos Grasos Volátiles/análisis , Femenino , Fármacos Gastrointestinales/administración & dosificación , Humanos , Ileostomía/efectos adversos , Péptidos y Proteínas de Señalización Intercelular/genética , Mucosa Intestinal/química , Péptidos y Proteínas de Señalización Intracelular , Masculino , Persona de Mediana Edad , Proctitis/etiología , Proctitis/patología , Proctitis/prevención & control , Proteínas/genética , Recto/efectos de los fármacos , Recto/patología , Transcriptoma/efectos de los fármacos , Vía de Señalización Wnt/genéticaRESUMEN
BACKGROUND: Migration from Latin American countries has increased the number of cases of chagasic megacolon in Western countries. Megacolon is a late complication of Chagas disease, resulting from irreversible destruction of the intramural intestinal nervous system with extensive loss of neurons, ganglionitis, and myositis at the sites of the myenteric and submucosal plexuses. Several surgical procedures involving partial or total resection of the dilated colon have been proposed for treating chagasic megacolon, but intra-operative evaluation of neuronal degeneration in the residual colon has not been commonly done. METHODS: Case report and literature review. CASE REPORT: We describe a case of chagasic megacolon treated successfully with a modified Habr-Gama technique, with the intra-operative examination of frozen sections of the residual segments of the colon for the presence of neurons. CONCLUSIONS: The recurrence of constipation after surgical treatment can result from the progression of chagasic neuronal degeneration in the preserved colon, and may be preventable by intra-operative evaluation of whether signs of neuronal degeneration or inflammation are absent in the anastomosed colonic tract.
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Enfermedad de Chagas/complicaciones , Colon/patología , Megacolon/patología , Megacolon/cirugía , Patología Quirúrgica/métodos , Procedimientos Quirúrgicos Operativos/métodos , Enema , Femenino , Secciones por Congelación , Histocitoquímica , Humanos , Microscopía , Persona de Mediana Edad , Radiografía AbdominalRESUMEN
INTRODUCTION: Desmoid tumors are rare benign tumors that originates in the fibrous sheath or musculo-aponeurotic structure. Histologically benign, they tends to invade locally and to be recurrent. PRESENTATION OF CASE: We report a rare case of an intra-abdominal desmoid tumor in a patient affected by familial adenomatous polyposis, which degenerated into abscess. Male, 38 years, was hospitalized for abdominal pain, bowel obstruction and fever. The computed tomography showed a big dishomogeneous mass occupying the whole mesentery with internal massive liquefaction. The mass extended from the epigastrium for 13cm up to L3. On the right mesogastric side a solid, thick mass of about 2cm, with a length of 4.5cm, was identified; it was not cleavable from the wall and from some of the loops. We decided to perform a computed tomography-guided percutaneous drainage. Two hundred ml of purulent necrotic material was aspirated, and washing with antibiotic solution was carried out. Cytological examination of fluid drainage showed histiocytes and neutrophils. At follow-up, the patient's clinical condition had improved. An abdominal ultrasound showed a substantial reduction in the diameter of the mass. DISCUSSION: Diagnosis and treatment of desmoids tumor in patients with familial adenomatous polyposis may be difficult, especially when desmoids are located intra-abdominally and in the mesentery. Seldom will desmoid tumors be complicated by abscess formation. CONCLUSION: The management of desmoids tumors is not easy and the choice of the best treatment may be difficult due to the different possible anatomical presentations.
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BACKGROUND: The relation between Crohn's colitis (CC) and colorectal cancer is still controversial. Several case reports and retrospective studies have shown that patients with Crohn's disease (CD) have a 6- to 20-fold higher risk to develop CRC than does the normal population. The extent of disease (extensive colitis), presence of anal fistula, age > 40 years, strictures, and length of disease >10 years may be important determinants for increasing risk. Despite this evidence, other population-based studies have shown no increased risk of colon or rectal cancer. The aim of this study was to investigate retrospectively factors that may predict the development of cancer. METHODS: We searched the histopathologic database of the Digestive Surgery Unit at Careggi University Hospital for CC patients (January 1987 to September 2011) and identified 313 patients with CC who underwent surgery. RESULTS: There are 11 (3.5 %) of adenocarcinomas. Multivariate analysis showed disease duration (p = 0.001), age at CD diagnosis (p = 0.002), distal localization (p = 0.045), and penetrating disease (p = 0.041) to be risk factors. Multivariate analysis showed that 40 patients who had undergone previous immunosuppressive therapy had a significant risk of developing CRC (p = 0.026). CONCLUSIONS: Crohn's colitis patients who require surgery are at higher risk for developing CRC, particularly those whose disease duration is >10 years, have distal localization, age at diagnosis was <40 years, and have penetrating disease. Previous immunosuppressive therapy should be better investigated. We recommend surgery for any patient presenting with colonic strictures.
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Adenocarcinoma/etiología , Colitis/complicaciones , Neoplasias Colorrectales/etiología , Enfermedad de Crohn/complicaciones , Adolescente , Adulto , Anciano , Niño , Preescolar , Colitis/cirugía , Enfermedad de Crohn/cirugía , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
BACKGROUND: The aim of the present study was to evaluate strictureplasty as the first choice for surgical treatment for Crohn's terminal ileitis. METHODS: Between 1996 and 2000 we performed Finney-shaped ileocecal strictureplasty (ICS), doubling up the diseased terminal ileum, in 14 patients affected by Crohn's disease (group A). We compared the postoperative and long-term outcomes of these patients with those of 14 similar patients who underwent ileocecal resection with ileocolonic anastomosis during the same period (group B). RESULTS: No postoperative morbidity or mortality was recorded in group A, whereas two patients of group B had a pelvic hematoma and cholestatic hepatopathy, respectively. The mean hospital stay after surgery was 9.9 days (range 7-13 days) in group A and 7.4 days (range 6-10 days) in group B. After a median follow-up of 120 months (range 103-147 months), five patients of group A had a symptomatic recurrence: A stricture at the site of the ICS was present in four of them, but only one required surgery; symptoms were controlled by medical therapy in the other three. The fifth symptomatic patient was reoperated for multiple jejunoileal recurrence of the disease above the ICS. Group B patients have been followed for a mean of 108 months (range 90-140 months). Four of the patients had a preanastomotic recurrence, with subocclusive symptoms and mild malnutrition treated with medical therapy. CONCLUSIONS: Our results indicate that there are no significant differences between ICS and resection in terms of outcome and clinical relapse of Crohn's terminal ileitis.