The experience of a referral centre and literature overview of GIST and carcinoid tumours in inflammatory bowel diseases.

Patients suffering from Inflammatory Bowel Diseases (IBD) are at increased risk of developing cancers of the gastrointestinal tract (GI). Adenocarcinomas are the most commonly observed GI tumours in IBD, and occur through an in inflammation-driven pathway. A trend toward reduced risk of bowel cancers has been observed in IBD in recent years, presumably related to improved medical treatments. However, some cancers may be independent from active inflammation, probably originating from altered interactions between the extremely active immune system of IBD patients and environmental factors. Data concerning gastrointestinal stromal tumours (GIST) and carcinoids tumours (CaT) of the GI in IBD patients are scanty. We report our experience with these rare cancers, and provide the readers with an overview on the topic, focussing on distinguishing and peculiar features of GIST and CaT of the GI in IBD compared with other cancer types and with general population, and address the treatment of such challenging conditions. Available data do not support an increased risk of GIST in IBD patients, but GI CaT may be more commonly observed in Crohn's disease. However, the presentation of GIST and GI CaT is protean and does not seem to be associated with disease activity in the involved GI segment in IBD. Conversely, some evidences suggest a potential role of inflammation in sustaining GI CaT in IBD. Increased awareness, longer duration of disease, and improved diagnostic modalities should also be considered when evaluating the increasing trend of CaT in CD patients. Treatment of GIST and CaT is not dissimilar from that of non-IBD patients, but prompt suspicion and diagnosis are crucial to achieve optimal outcomes.

Gallstone ileus without bilioenteric fistula years after bypass surgery for Crohn's disease. Case report and clues to etiology of a neglected cause of obstruction.

INTRODUCTION: Gallstone ileus is a very rare cause of bowel obstruction. Patients suffering from Crohn's disease are at increased risk of developing gallstone disease, especially when terminal ileum is involved. Gallstone ileus can occur, but etiology remains controversial. We report on a case of such a rare condition, illustrating etiology and treatments. PRESENTATION OF CASE: A patient with long-standing Crohn's disease, who had undergone ileotransverse bypass for ileocaecal involvement 40 years before, presented with cramp-like abdominal pain. Imaging was consistent with a gallstone ileus with no evidence of bilioenteric fistulae. DISCUSSION: At surgery, we found gallstones stuck at the site of ileotransverse anastomosis. No bilioenteric fistulae were found. Due to disease progression, many enteric fistulae were found, requiring a massive bowel resection. The diverted segment may have been responsible of gallstone formation, and etiology is discussed. Recovery after surgery was uneventful, but the patient required continued nutritional support. CONCLUSION: Physicians dealing with Crohn's disease patients with bypassed segments should keep in mind, the increased risk of gallstone formation, in order to not overlook gallstone ileus. Early suspect and diagnosis may allow for less aggressive approaches. A diverted segment should always be removed, and long-term follow-up encouraged.

Hormonal contraceptives and venous thromboembolism: Are inflammatory bowel disease patients at increased risk? A retrospective study on a prospective database.

Recent studies showed an increased risk of venous thromboembolism (VTE) in patients receiving oral hormonal contraceptives. Inflammatory bowel diseases (IBD) often affect young patients and represent a pro-coagulant condition. This could result from active inflammation, but a potential role for genetic and molecular factors has been suggested. Hormonal contraceptives have also been associated with increased risk of VTE and the risk may be greater in IBD patients that already are in a pro-coagulant status, but no definitive data are available in this population. The purpose of our study was to seek for differences of the risk of VTE in IBD patients receiving hormonal contraceptives compared with controls. This is a retrospective study. We interrogated a prospectively maintained database of IBD patients observed at our outpatient clinic between 2000 and 2014. All female patients managed conservatively, with no active disease, who were taking oral hormone contraceptives in the study period, were included. Patients observed for other-than-IBD conditions at our Unit and at the Unit of Gynaecology and Obstetrics, receiving contraceptives, served as controls (ratio 1:2). Patients with cancer, those receiving hormonal therapy, and those with known genetic predisposition to VTE were excluded. We included 146 six IBD patients and 290 controls. One patient in each group developed VTE. Overall, the incidence of VTE associated with oral contraceptives was 0.5%. IBD was associated with increased risk of VTE (OR 1.9, 95% CI 0.12-32.12, p > 0.99). Active smokers since 10 years (17.2%) had higher risks of VTE (OR 8.6, 95% CI 1.16-19.25, p = 0.03). Our data show that patients with IBD in remission are not at higher risk of VTE due to oral oestrogen-containing contraceptives compared with non-IBD controls. Smokers are at increased risk, irrespective of the baseline disease.

The effects of low-thrombin fibrin sealant on wound serous drainage, seroma formation and length of postoperative stay in patients undergoing axillary node dissection for breast cancer. A randomized controlled trial.

BACKGROUND: Breast cancer surgery with axillary lymphadenectomy may be associated with prolonged stay of the drain in the axilla due to high wound output, which may require further treatments and prolong the length of stay, impairing quality of life. No definitive data are available concerning how to prevent this complication. Our aim was to assess the efficacy of a new low-thrombin fibrin glue in reducing the serous output from the axillary surgical wound in patients undergoing axillary node dissection for breast cancer, and its long-term effects on lymphedema. METHODS: Sixty patients undergoing surgery between September 2012 and June 2013 were enrolled. Thirty patients received Artiss®(Baxter, UK) fibrin glue plus drainage, and 30 drainage alone. A multivariate analysis was performed to identify predictors of seroma, and subgroup analyses were performed. Lymphedema was assessed 12 months after surgery. RESULTS: Patients who received fibrin glue had reduced serum output collected in the drain after surgery (94.3 ± 22.4 vs 176 ± 24.6 ml p < 0.001) and shorter length of postoperative hospital stay (p = 0.001). Incidence of seroma at 4-week follow-up did not differ between groups. At multivariate analysis, BMI ≥ 30 kg/m(2) was the only independent predictor of seroma formation (OR = 2.7, 95%CI 1.4-5.3; p = 0.002). Overweight patients receiving Artiss® had fewer seroma at 4-week follow-up compared with control overweight patients (0% vs 55.6%, p = 0.03). No differences were observed in lymphedema between groups (6.7% vs 10%, p > 0.99). CONCLUSIONS: Low-thrombin fibrin glue reduced the amount of fluid produced in the axilla after breast surgery. Overweight patients may be the ideal candidates for this treatment. Such sealant did not increase the rates of lymphedema.

Thyroid surgery in the elderly: a comparative experience of 400 patients from an Italian university hospital.

The aim of this study was to compare disease features and surgical complications of patients undergoing surgery under or over 65 years of age. We performed a retrospective review of patients undergoing thyroidectomy or lobectomy from January 1990 through January 2012 in our Institution. Patients aged over 65 years of age were compared with younger patients on a 1:1 ratio. A total of 2012 patients were operated on during the study period. Two-hundred patients aged > 65 years were compared with 200 patients < 65 years old. In this series, no significant differences were observed concerning surgical complications between groups. At multivariate analysis, masses causing compression, extended approaches and malignant lesions were significant predictors of complications, irrespective of age. Due to longer life expectancy, elderly patients are being operated on more frequently. Safety of thyroid surgery in this population is still debated. We observed no difference in surgical outcomes between elderly and younger patients; however, some features of the diseases impair survival in the former. Age did not increase likeliness of worse outcomes in patients receiving thyroid surgery.

Preventive NPWT over closed incisions in general surgery: does age matter?

Surgical site events (SSE), including surgical wound complications and surgical site infections, are a major concern in patients undergoing general surgery operations. These increase the costs of care, and can lead to prolonged hospital stay and need for further treatments, ultimately resulting in poor quality of life. Negative pressure wound therapy (NPWT) has been recently reported as a preventive strategy to avoid SSE, but little is known on the topic, and particularly in geriatric population. Our primary aim was to assess the efficacy of NPWT by means of a pocket device (PICO, Smith & Nephew, London, UK) in preventing SSE compared with conventional dressings in patients undergoing surgery with primary wound closure for breast and for colorectal diseases in our Unit. Our secondary aims were to assess the efficacy and safety of PICO in elderly patients, and to seek for differences between breast and abdominal results. All consecutive patients undergoing breast and colorectal surgery in our Unit between September 2012 and May 2014 were prospectively enrolled in this open label controlled study. Breast patients receiving NPWT were assigned to group B1, those receiving conventional dressings were assigned to group B2. Colorectal patients were assigned to group C1 (NPWT) and C2 (conventional dressings) in similar fashion. Each group included 25 patients, and at least 10 (40%) patients aged over 65 years to allow sub-analyses. NPWT significantly reduced SSE in both breast and colorectal patients compared with controls. No significant differences were observed according to age. Similar benefits were observed in breast and colorectal patients. Our results suggest that PICO is an effective tool to prevent SSE in patients undergoing general surgery, irrespective of age. Its use is recommended in frail, elderly patients at risk of SSE.

Restorative proctocolectomy with ileal pouch-anal anastomosis is safe and effective in selected very elderly patients suffering from ulcerative colitis.

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis is the mainstay treatment for intractable or refractory ulcerative colitis (UC). Safety and effectiveness of RP in elderly patients are debated. Our aim was to compare surgical outcomes and function of patients undergoing RP over 80-year-of-age with those of younger controls. We retrospectively gathered data of patients receiving RP for UC aged >80 years between January 1990 and December 2012. A control group of younger patients was established for comparison (1:3 ratio). Functional outcomes and satisfaction with surgery 6 and 12 months after ileostomy closure were collected. Ten patients >80-year-old were included (median age 87.5, range 84-90 years). All patients had at least one comorbidity (mean 2.1 ± 1) and were receiving medications for concomitant diseases. Half of them received a 3-stage procedure. Neither death nor major perioperative complications were observed. One patient (10%) required readmission for dehydration 2 weeks after RP with loop-ileostomy. Thirty younger patients (median age 34.3, range 25-52 years) served as controls. All patients had their ileostomy closed within 3 months from RP. At 6 month follow-up, elderly patients had more nocturnal seepage, antidiarrhoeals intake, and a trend toward more frequent day-time incontinence. At 12-month follow-up differences were less apparent. Only nocturnal seepage was higher in elderly. All patients retained their pouch and would have undergone surgery again. RP is feasible in selected advanced age patients, and functional results are comparable to younger patients.

Fatigue in inflammatory bowel diseases: relationship with age and disease activity.

A higher rate of patients suffering from inflammatory bowel diseases (IBD) are reported to experience the symptom of fatigue compared with general population. Fatigue can impair quality of life of IBD patients by limiting their daily functioning. However, this problem is poorly understood and addressed. Our aim was to investigate the impact of fatigue in IBD patients compared with controls, and to seek for relation between age and disease activity. IBD patients aged between 16 and 75 years observed at our Unit from June 2011 through June 2012 were evaluated for fatigue. Patients were asked to fill the fatigue impact scale (FIS) questionnaire. A cohort of age- and sex-matched patients observed for other-than-IBD diseases were prospectively enrolled to act as controls. Patients diagnosed with malignancies were excluded from evaluation. Each group included 16 patients, of whom half aged over 65 years. Fatigue was more severe in IBD patients than in controls (p = 0.02), irrespective of age and disease activity. IBD patients with moderate to severe disease activity showed worse fatigue compared with controls at any age (p < 0.0001). Young IBD patients with low disease activity showed a trend toward worse FIS score when compared with old IBD counterparts (p = 0.06). IBD significantly impacted on fatigue in our series. Considering IBD patients in remission, younger patients may experience worse fatigue. Further studies are needed to explore the effects of fatigue on quality of life and the potential of appropriate intervention strategies.

Relatives of Crohn's disease patients and breast cancer: an overlooked condition.

Recent data suggest that patients suffering from Crohn's disease (CD) may be at higher risk of developing extra-intestinal malignancies. This is attributed to inflammation and immunodepression due to medications. However, a genetic predisposition cannot ruled out. In the present study we investigated the prevalence of breast cancer in first-degree female relatives of CD patients compared with relatives of patients without evidence of gastrointestinal diseases. A total of 1302 female first-degree relatives of CD patients and 1294 relatives of controls were included. We found that CD was an independent risk factor for breast cancer development (OR = 2.76, 95% CI = 1.2-6.2; p = 0.017), and this is particularly evident in mothers (3.6% vs 1%, p = 0.009 - OR = 3.7, 95% CI 1.4-10). Among CD group, smoking habit of CD patients was associated with increased risk of cancer compared with relatives of non-smokers (7.7% vs 2.9%, p = 0.01 - OR = 2.8 95% CI 1.2-6.6). Intriguingly, stage at diagnosis was significantly higher in CD relatives (p = 0.04). Our findings suggest that first-degree female relatives of CD patients are at higher risk of developing breast cancer but receive diagnosis at more advanced stages, therefore advocating the need of more active screening protocol in this population.