Oral butyrate for mildly to moderately active Crohn's disease.

BACKGROUND: Butyrate exerts anti-inflammatory effects in experimental colitis and on Crohn's disease lamina propria mononuclear cells in vitro. AIM: To explore the efficacy and safety of oral butyrate in Crohn's disease. METHODS: Thirteen patients with mild-moderate ileocolonic Crohn's disease received 4 g/day butyrate as enteric-coated tablets for 8 weeks. Full colonoscopy and ileoscopy were performed before and after treatment. Endoscopical and histological score, laboratory data, Crohn's disease activity index and mucosal interleukin (IL)-1beta, IL-6, IL-12, interferon-gamma, tumour necrosis factor-alpha and nuclear factor-kappa B (NF-kappaB) were assessed before and after treatment. RESULTS: One patient withdrew from the study, and three patients did not experience clinical improvement. Among the nine patients (69%) who responded to treatment, seven (53%) achieved remission and two had a partial response. Endoscopical and histological score significantly improved after treatment at ileocaecal level (P < 0.05). Leucocyte blood count, erythrocyte sedimentation rate and mucosal levels of NF-kappaB and IL-1beta significantly decreased after treatment (P < 0.05). CONCLUSIONS: Oral butyrate is safe and well tolerated, and may be effective in inducing clinical improvement/remission in Crohn's disease. These data indicate the need for a large investigation to extend the present findings, and suggest that butyrate may exert its action through downregulation of NF-kappaB and IL-1beta.

Intestinal perforation as a long-term complication of plug and mesh inguinal hernioplasty: case report.

Tension-free and sutureless hernioplasty by plug and mesh of nonreabsorbable material is one of the most common techniques for inguinal hernia repair. It's a simple and quick procedure with a low cost and allows for a short hospital stay. It shows a low reoccurrence rate, but it can result, in very few cases, in complications strictly related to prosthetic material. The literature describes some cases of plug migration from its proper position, for example, to the scrotum, preperitoneal adipose tissue, and abdominal cavity. We report on a case of sigmoid colon perforation due to a plug of Trabucco hernioplasty performed 2 years previously.

Immunoglobulin M memory B cell decrease in inflammatory bowel disease.

BACKGROUND & OBJECTIVES: Memory B cells represent 30-60% of the B cell pool and can be subdivided in IgM memory and switched memory. IgM memory B cells differ from switched because they express IgM and their frequency may vary from 20-50% of the total memory pool. Switched memory express IgG, IgA or IgE and lack surface expression of IgM and IgD. Switched memory B cells derive from the germinal centres, whereas IgM memory B cells, which require the spleen for their survival and/or generation, are involved in the immune response to encapsulated bacteria. Since infections are one of the most frequent comorbid conditions in inflammatory bowel disease, we aimed to verify whether IgM memory B cell pool was decreased in Crohn's disease and ulcerative colitis patients. PATIENTS & METHODS: Peripheral blood samples were obtained from 22 Crohn's disease patients, 20 ulcerative colitis patients, 22 healthy controls and 18 splenectomized patients. To analyse peripheral blood lymphocytes, flow cytometry was performed using anti-CD19, anti-CD22, anti-CD27, anti-IgM, anti-IgD and anti-CD38 monoclonal antibodies. RESULTS: Circulating IgM memory B cells were significantly lower in Crohn's disease (median 7.1%, range 1.8-20.7) and ulcerative colitis patients (median 8.1%, range 2.1-18.8) in comparison to control subjects (median 14.0%, range 6.8-31.1). As expected, there was a highly significant difference in the proportion of IgM memory B cells between splenectomized patients (median 2.4%, range 0.9-6.9) and healthy controls. Crohn's disease patients with abscesses showed the lowest frequency of IgM memory B cells. DISCUSSION: Our findings show that peripheral IgM memory B cells are reduced in inflammatory bowel disease patients. Further studies are necessary to answer the question of whether high risk of infection (abscess development) is promoted by the reduction/depletion of IgM memory B-cell pool in inflammatory bowel disease.

[Clinical and functional results after restorative proctocolectomy with ileal J reservoir in the treatment of ulcerative colitis]. / Risultati clinici e funzionali dopo proctocolectomia restaurativa con serbatoio ileale a J nel trattamento della colite ulcerosa.

PURPOSE: Restorative proctocolectomy is the procedure of choice in the treatment of ulcerative colitis. The operation is successful in removing all diseased mucosa while preserving a normal bowel function and a good quality of life for the patient. In this article are presented the clinical and functional results obtained in 28 patients, 19 males (68%) and 9 females (32%) after stapled restorative proctocolectomy with ileal J pouch-anal anastomosis. RESULTS: There were no perioperative deaths. The overall morbidity rate was 31%. Six patients (21%) presented pelvic abscess; 2 (7%) pelvic hematoma, 4 patients (14%) ileo-anal anastomotic stricture, 1 patient (3.6%) pouch-vagina fistula, three patients (11%) intestinal obstruction and 7 (25%) pouchitis. All patients were able to evacuate their pouches spontaneously. The mean bowel movements were 6-9/24 hours at the first postoperative month and 3-5/24 hours at the sixth month. Infrequent nocturnal seepage occurred in 6 patients (21%). Stool consistency returned to normal within 3-6 months. The mean pouch capacity was 210 cc. The mean resting pressure was diminished in 11 patients (39%), the men and maximal squeeze pressures were improved in 9 (32%); the ileo-rectal-anal inhibitory reflex was normal in 5 patients (18%), not defined in 12 (43%). Impotence or impaired bladder function was not present. CONCLUSION: The use of staplers in the surgical technique of restorative proctocolectomy with J shaped ileo-anal pouch is associated with low morbidity and better long-term results. The procedure requires a good selection of patients, a correct surgical timing, a very carefully technique and a low pre and postoperative treatment with steroids.

[Aspects of the complications after restorative proctocolectomy in the treatment of ulcerative colitis. Review of the literature and personal experience]. / Aspetti delle complicanze dopo proctocolectomia restaurativa nel trattamento della colite ulcerosa. Revisione della letteratura ed esperienza personale.

PURPOSE: Analysis of complications and causes of failure after stapled restorative proctocolectomy with ileal J pouchanal anastomosis in patients with ulcerative colitis is presented. PATIENTS AND METHODS: The procedure was performed in 28 patients, 19 males (68%) and 9 females (32%); diverting ileostomy was always performed. RESULTS: There was no perioperative mortality. The overall morbidity rate was 31%. Six patients (21%) had pelvic abscess, 2 (7%) pelvic hematoma, 4 patients (14%) presented ileo-anal anastomotic stricture, 1 patient (3.6%) had pouch-vaginal fistula, three patients (11%) presented intestinal obstruction and 7 (25%) pouchitis. Reoperation was necessary in patients with small bowel obstruction and with pouch-vaginal fistula. Septic complications and pouchitis were resolved with medical treatment. Stenosis of the anastomosis required anal dilation. No patient underwent pouch excision for pouch failure. CONCLUSION: The main significant complications of ileal pouch-anal anastomosis for ulcerative colitis were pelvic sepsis, intestinal obstruction and pouchitis. Our results suggest that the use of stapling technique is safer and has fewer early septic complications and sepsis-related pouch removals. Success in ileo-anal construction increases with experience. The selection of patients with exclusion of Crohn disease, a correct surgical timing, a carefully technique, a delayed ileostomy closure and a low pre and postoperative regimen of steroids are important factors of success.

[Portal hypertension and enterostomy: a dangerous combination. Colostomy-induced varices as a rare cause of gastrointestinal hemorrhage. Report of a case and review of the literature]. / Ipertensione portale ed enterostomia: un binomio a rischio. Le varici colostomiche come causa rara di enterorragia. Descrizione di un caso e revisione della letteratura.

Variceal bleeding from enterostomy in an unusual complication of portal hypertension. The hemorrhage can be managed in most patients with local measures, but if these manouvres fail, surgical procedures may be required. Treatment options include pressure dressings, stomal revision or disconnection, suture or ligation of stomal varices, bowel resection, and porto-systemic shunting. Recently sclerotherapy and percutaneous transhepatic embolization have been reported. A case of ectopic varices in the site of colostomy complicated by recurrent hemorrhage is described and the therapeutic option utilized is discussed with review of Literature to assess the efficacy of the various treatment options.

[Reconversion after Hartmann's procedure. Our experience]. / Ricanalizzazione dopo Hartmann. Nostra esperienza.

An increasing number of intestinal reconversion after Hartmann have been performed in recent years, especially due to improved surgical techniques and progressively lengthened lifespan. The authors report 33 cases of intestinal recanalization of 100 interventions according to Hartmann from 1984 to 1996 (21 not neoplastic pathologies, 12 neoplasias). The variables considered included: patient age, type of disease requiring intervention according to Hartmann, oncologic characteristic of patients with neoplasia, interval between the two interventions, preoperative examinations performed, morbidity and mortality after reconversion. Furthermore, the fundamental indications for reconversion are described, in particular in patients with neoplasias (CEA, transanal echo, total body Ct, anal manometry). The low frequency of preoperative complications, zero mortality, satisfactory long-term follow-up (only one patient with neoplastic relapse) indicate that colon-rectal reconversion can also be performed in the elderly and patients with neoplasias with favorable prognosis.

[Familial adenomatous polyposis. Problems encountered with rectum preservation in surgical treatment and life expectancy]. / La poliposi adenomatosa familiare. Problemi offerti dalla conservazione del retto nel trattamento chirurgico ed aspettative di vita.

Familial adenomatous polyposis is a genetically inherited disease with very high risk of colorectal cancer and with a large expression of multiple extracolonic malignancies. In recent years two surgical options are available for the treatment of FAP: total colectomy with ileorectal anastomosis and restorative proctocolectomy with ileoanal reservoir. The preservation of the rectum offers good quality of life and good functional results, but needs an accurate surveillance of the rectal stump and screening for the development of cancer. Restorative proctocolectomy is reserved for patients with large or confluent polyps of the rectum, for older patients and for those who had already had an ileorectal anastomosis and who develops subsequently large adenomas at increased risk for rectal cancer. Prophylactic procedures of surveillance, screening and surgery have reduced in patients at risk the incidence of colorectal cancer. But recently an increased number of malignant extracolonic tumors (gastric cancer, duodenal and periampullary cancer, small intestinal cancer, adrenal and thyroid cancer) and abdominal desmoid tumors, that causes a significant mortality, has been documented. The knowledge of the extracolonic features of FAP suggests a careful follow-up of the patients and the prevention and treatment of upper gastrointestinal cancers and desmoid disease.

[Massive hemorrhage caused by colonic diverticulosis]. / L'emorragia massiva da diverticolosi colica.

Massive hemorrhage from diverticular disease of the colon is a very difficult problem in abdominal emergency surgery. The pathogenesis of bleeding colonic diverticulosis is strictly correlated to the angioarchitecture of the colonic diverticular wall. Here the vasa recta penetrate the colonic wall from the serosa to the submucosa through connective tissue septa. Injurious factors arising from the colonic or diverticular lumen can produce an eccentric damage to the luminal side with intimal thickening, segmental weakening of the artery and its rupture with massive bleeding. Conventional barium enema is not able to show the source of the hemorrhage in the majority of the bleeding patients; colonoscopy, as primary emergency procedure, has significant positive findings in 41.5%-83.7% of patients. Radionuclide bleeding scans have a sensitivity rate of 86%-94%. Emergency arteriography localizes the bleeding source in higher rates ranging from 58% to 86% and is successful after intraarterial infusion of vasopressin or embolization in 47%-92% of patients. Surgical treatment for continued bleeding from diverticular disease is controversy. Segmental resection should be performed on patients with localized bleeding sources (positive arteriogram). Laparotomy, anterograde irrigation and intraoperative colonoscopy are indicated in patients with multiple bleeding sites and negative arteriography. Because the right colon is the most common site of bleeding in same cases is necessary to perform a subtotal colectomy with ileorectal anastomosis. Blind resections particularly in the elderly patients present high rebleeding rate (> 60%) and high mortality (30%) with sepsis accounting for the majority of deaths.

[Large abdominal incisional hernias, use of prosthesis. Our experience]. / Considerazioni sui grandi laparoceli addominali, l'utilizzo di protesi. La nostra esperienza.

Retrospective analysis of risk-factors in 241 patients with large abdominal incisional hernia collected in a 16-year period at the Department of Surgery, University of Pavia, allows the Authors to identify the aetiological mechanism of herniation and to discuss the fundamental technical skills in wall reconstruction. The recurrence rate after primary repair was 30% (63/209 patients). In 32 patients (13.3%) plastic prosthesis was used. The side of recurrent herniation was upper midline in 12 patients (37.5%), lower midline in 6 patients (19%), right lower quadrant in 8 patients (25%), right and left flank in 4 (12.5%) and in 2 patients (6.25%) respectively. Plastic repair was performed with a polytetrafluoroethylene graft (PTFE) in 19 patients (59%), with a polypropylene mesh in 7 patients (22%); woven polyethylene mesh was used in 6 patients (19%). Recurrence after prosthetic repair was seen in 5/32 patients (15.6%) and was correlated to local sepsis in patients with poor nutritional status. The PTFE mesh was considered useful to reduce the recurrence rate of hernias and the postoperative disability. It was associated with good elasticity, adequate strength, satisfactory tissue acceptance and minimal risk of infection. However the best results need a careful preoperative evaluation, no tension on the suture line, the prevention and properly treatment of postoperative complications.

[Primary malignant neoplasms of the liver. Contribution of echography to the preoperative diagnosis]. / Neoplasie maligne primitive del fegato. Contributo dell'ecografia alla diagnosi preoperatoria.

Primary malignant hepatic tumors are relatively common and the possibility of radical surgical treatment in the initial stages has modified our clinical approach therefore stressing the validity of a correct screening and follow-up of this pathology. The Authors present their clinical experience in the field enriched by the use of ultrasonography and conclude that this represents a highly effective diagnostic technique whereas it is less reliable in the determination of the nature of the lesion.

[Postoperative external biliary fistulas: personal case series]. / Fistole biliari esterne post-operatorie: casistica personale.

Over the period 1974-1986, five patients with external biliary fistulas were admitted to our clinic. The fistulas set in as complications of surgical operations due in 3 cases to a Kehr drainage of the common bile duct, in 1 case to drainage of a subhepatic abscess and in 1 case to pancreatic hydatid cyst. The causes of onset of the fistulas are reported as well as the therapy adopted in each case.

Efficacy and tolerance of ceftazidime in the treatment of post-operative respiratory tract infections.

Ceftazidime proved particularly effective in the treatment of acute respiratory tract infections arising in the immediate post-operative period, affording complete clinical cures in 88.8% of cases and a substantial improvement in the pathological picture in the other 11.2% of cases treated. The authors also draw attention to the excellent tolerance of the antibiotic, as evaluated on the basis of liver and kidney function and blood chemistry parameters and the total absence of adverse reactions.

[Controlled clinical study on the efficacy of tiropramide hydrochloride in the treatment of irritable colon: comparison with octylonium bromide]. / Studio clinico controllato sull'efficacia della tiropramide cloridrato nel trattamento del colon irritabile: confronto con ottilonio bromuro.

The effectiveness of a new calmodulin-independent spasmolytic, tiropramide hydrochloride, and octylonium bromide, an antispasmodic calmodulin-antagonist drug, was compared in a controlled trial performed in 60 patients with irritable bowel syndrome with spastic pattern. The effect of treatments was assessed according to the score reduction of following symptoms: abdominal pain, constipation, bloating and dyspepsia. Tiropramide hydrochloride administered at the daily dose of 300 mg for 30 days induced a faster and higher improvement than that observed during the administration of 120 mg daily of octylonium bromide. On 3rd and 5th day, treatment with tiropramide induced the relief of abdominal pain in a significantly greater percentage of patients (p less than 0.05). Besides, in the group of subjects treated with this drug the "pain" score was more markedly decreased. Furthermore, at the end of the study 88% of subjects treated with tiropramide and 47% with octylonium bromide had normal bowel habits. This difference was statistically significant (p less than 0.05). Both treatments are effective in reducing dyspeptic symptoms and bloating. We can conclude that tiropramide--having a significant antispasmodic effect combined with a regulating effect on bowel habits--besides eliminating spasm, would act by synchronizing and therefore normalizing the intestinal motility.

[Alkaline reflux after gastric resection using the Billroth II method]. / Il reflusso alcalino dopo resezione gastrica secondo Billroth II.

Among the more indicative complications encountered in gastrectomized patients, particularly in those cases where the Billroth II technique is used, bile and/or pancreatic reflux is undoubtedly one of the most important manifestations. The abolition of the "sphincteric" function of the pylorus creates a pathophysiological condition of the above-mentioned type when the surgery is not combined with specific antireflux techniques or when particular situations obtain which make alkaline reflux inevitable. These pathophysiological disorders lead to a "chronic gastritis of the stump", which often exhibits differing symptomatic pictures. There are patients in whom there is no correspondence between the anatomo-pathological and symptomatic pictures and who do not suffer at all, phereas there are others (5-35%) who complain of severe symptoms such as epigastric pain aggravated by ingestion of food, reduction in weight, nausea, bile vomiting and often haemorrhagic stillicide with consequent sideropaenic hypochromic anaemia. Taking the above-mentioned considerations as their starting point, the authors set out to investigate these complications more thoroughly in the pathology of gastrectomized patients by means of the long-term follow-up of such patients coming to them for observation after having been subjected to surgical therapy in the form of Billroth II gastric resection (gastro-enterostomy according to Balfour-Kroenlein, or according to Hofmeister-Fininsterer). The study, which is currently still in progress, involves a thorough clinical examination of the symptoms complained of as well as radiological, gastroscopic, histological and haematochemical investigations. The authors report on their preliminary results.