Surgical management in intestinal Crohn’s disease

Hyperbaric Oxygen Therapy in the Treatment of Crohn's Disease

Background/Objectives: Our study describes hyperbaric oxygen therapy (HBOT) as an additional therapy in the conservative treatment of Crohn's disease (CD) and its benefit in the early postoperative period to prevent surgical complications and improve gastrointestinal motility. Methods: This retrospective study evaluated HBOT in patients hospitalized at the Clinical Hospital Center Split for complications of CD between 2015 and 2020. Patients (N = 61) aged 19 to 67 with perianal fistulas, abscesses, fistulas, obstruction, stenosis, or bleeding were included, excluding those with ulcerative colitis or requiring intensive care. Patients were retrospectively divided into conservatively and surgically treated groups, and HBOT was administered over 15-25 days, with treatment lasting 60 min at 2.2 absolute atmospheres (ATA). We analyzed treatment outcomes between the HBOT-treated surgical and conservative groups and compared patients treated with HBOT to a cohort from the preceding five years who did not receive HBOT. Results: We treated 61 CD patients with HBOT, including 34 conservatively and 27 surgically treated patients. HBOT significantly reduced disease activity indices (311.7 ± 59.1 vs. 114 ± 29.8; 203.6 ± 24.1 vs. 83.8 ± 15, for conservatively treated patients, and 352.8 ± 45.7 vs. 109 ± 22.8; 270.4 ± 19.7 vs. 140.3 ± 10.6 for surgically treated patients) and accelerated bowel peristalsis recovery, with 94.1% of conservatively treated patients achieving remission. Comparison with a historical cohort showed faster recovery and improved outcomes in the HBOT group. Conclusions: HBOT is useful in postponing or avoiding surgical treatment, and in operated patients, it improves postoperative recovery and reduces the rate of postoperative complications.

Circulating hematopoietic stem cells and putative intestinal stem cells in coeliac disease

Background

The intestinal stem cells (ISC) modulation and the role of circulating hematopoietic stem cells (HSC) in coeliac disease (CD) are poorly understood. Our aim was to investigate the longitudinal modifications in peripheral blood HSC traffic and putative ISC density induced by gluten-free diet (GFD) in CD.

Methods

Thirty-one CD patients and 7 controls were enrolled. Circulating CD133⁺ and CD34⁺ HSC were measured by flow cytometry, at enrolment and after 7 days and 1, 3, 6, 12, and 24 months of GFD. Endoscopy was performed at diagnosis and repeated at 6, 12, and 24 months following GFD. We used the Marsh-Oberhuber score to evaluate the histological severity of duodenal damage; immunohistochemistry was employed to measure the intraepithelial lymphoid infiltrate (IEL, CD3⁺ lymphoid cells) and the putative ISC compartment (CD133⁺ and Lgr5⁺ epithelial cells).

Results

At enrolment, circulating HSCs were significantly increased in CD patients and they further augmented during the first week of GFD, but progressively decreased afterwards. CD patients presented with villous atrophy, abundant IEL and rare ISC residing at the crypt base. Upon GFD, IEL progressively decreased, while ISC density increased, peaking at 12 months. After 24 months of GFD, all patients were asymptomatic and their duodenal mucosa was macroscopically and histologically normal.

Conclusions

In active CD patients, the ISC niche is depleted and there is an increased traffic of circulating HSC versus non-coeliac subjects. GFD induces a precocious mobilization of circulating HSC, which is followed by the expansion of the local ISC compartment, leading to mucosal healing and clinical remission.

Mesenchymal stem cells and conditioned medium avert enteric neuropathy and colon dysfunction in guinea pig TNBS-induced colitis

Damage to the enteric nervous system (ENS) associated with intestinal inflammation may underlie persistent alterations to gut functions, suggesting that enteric neurons are viable targets for novel therapies. Mesenchymal stem cells (MSCs) offer therapeutic benefits for attenuation of neurodegenerative diseases by homing to areas of inflammation and exhibiting neuroprotective, anti-inflammatory, and immunomodulatory properties. In culture, MSCs release soluble bioactive factors promoting neuronal survival and suppressing inflammation suggesting that MSC-conditioned medium (CM) provides essential factors to repair damaged tissues. We investigated whether MSC and CM treatments administered by enema attenuate 2,4,6-trinitrobenzene-sulfonic acid (TNBS)-induced enteric neuropathy and motility dysfunction in the guinea pig colon. Guinea pigs were randomly assigned to experimental groups and received a single application of TNBS (30 mg/kg) followed by 1 × 10(6) human bone marrow-derived MSCs, 300 μl CM, or 300 μl unconditioned medium 3 h later. After 7 days, the effect of these treatments on enteric neurons was assessed by histological, immunohistochemical, and motility analyses. MSC and CM treatments prevented inflammation-associated weight loss and gross morphological damage in the colon; decreased the quantity of immune infiltrate in the colonic wall (P < 0.01) and at the level of the myenteric ganglia (P < 0.001); prevented loss of myenteric neurons (P < 0.05) and damage to nerve processes, changes in ChAT, and nNOS immunoreactivity (P < 0.05); and alleviated inflammation-induced colonic dysmotility (contraction speed; P < 0.001, contractions/min; P < 0.05). These results provide strong evidence that both MSC and CM treatments can effectively prevent damage to the ENS and alleviate gut dysfunction caused by TNBS-induced colitis.

Regenerative medicine: prospects for the treatment of inflammatory bowel disease

This article reviews the current understanding of the processes driving the development and progression of inflammatory bowel disease (IBD), discusses how the dynamic crosstalk between resident microorganisms, host cells and the immune system is required in order to maintain immune homeostasis, and considers innovative strategies that allow the modification or modulation of the intestinal microorganismal community as a potential approach for treating IBD. This article next rationalizes the use of cell-based regenerative medicine as treatment for IBD, discusses the obstacles hindering its success, summarizes some of the results of recent clinical trials employing these therapies, and discusses ongoing work to enhance mesenchymal stem/stromal cells, making them better suited to the task of repairing the damage within the IBD gut.

The surgical options and management of intestinal Crohn's disease

Crohn's disease (CD) is a pan-gastrointestinal illness. It is notorious for recurrences which can develop in any segment of the gastrointestinal tract. There are many indications and surgical options for intestinal Crohn's disease . We discuss these options based on the current literature. It is important to note however, that operative treatment is based on the correct diagnosis, clinical presentation, sphincter function and patient motivation. Early and timely referral to a surgeon is paramount. The goals of continued medical therapy need to be clearly defined as do the criteria for referral to surgery.

Mesenchymal cells of the intestinal lamina propria

The mesenchymal elements of the intestinal lamina propria reviewed here are the myofibroblasts, fibroblasts, mural cells (pericytes) of the vasculature, bone marrow-derived stromal stem cells, smooth muscle of the muscularis mucosae, and smooth muscle surrounding the lymphatic lacteals. These cells share similar marker molecules, origins, and coordinated biological functions previously ascribed solely to subepithelial myofibroblasts. We review the functional anatomy of intestinal mesenchymal cells and describe what is known about their origin in the embryo and their replacement in adults. As part of their putative role in intestinal mucosal morphogenesis, we consider the intestinal stem cell niche. Lastly, we review emerging information about myofibroblasts as nonprofessional immune cells that may be important as an alarm system for the gut and as a participant in peripheral immune tolerance.