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Ferreira SDC, Aprile LRO, Parra RS, Feitosa MR, de Castro PPM, Perdoná GDCDS, Feres O, da Rocha JJR, Troncon LEDA. Factors associated with surgical resection in patients with Crohn's disease: long-term evaluation. Acta Cir Bras 2024; 39:e391924. [PMID: 38629651 PMCID: PMC11020661 DOI: 10.1590/acb391924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/05/2024] [Indexed: 04/19/2024] Open
Abstract
PURPOSE To evaluate patient characteristics and factors associated with surgical resection in patients with Crohn's disease (CD). METHODS An analysis was performed on data from 295 patients with CD in follow-up from 2001 to 2018. Medical record data comprised age, gender, location, behavior and duration of the CD, smoking, and extraintestinal manifestation. Patients were divided into two groups according to the presence or absence of surgical resection. RESULTS Out of the 295 patients with CD, 155 underwent surgical resection (53.2% male, mean age: 43.88 ± 14.35 years). The main indications for surgery were stenosis (44.5%), clinical intractability (15.5%), and intra-abdominal fistulas (15.5%). Smoking (p < 0.001), longer CD duration (p < 0.0001), ileo-colonic location (p = 0.003), stenosing behavior (p < 0.0001), and fistulizing behavior (p < 0.0001) were significantly associated with surgical resection. Initial use of biological was significantly more frequent in the group of patients without surgical resection (p < 0.001). CONCLUSIONS Patients with CD still frequently need surgical treatment. Smoking (current or past), longer disease time, stenosing and fistulizing behavior, and ileo-colonic localization in CD patients were associated with a higher risk of surgery. Awareness about factors associated with unfavorable outcome allows such patients to be treated more appropriately.
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Affiliation(s)
- Sandro da Costa Ferreira
- Universidade de São Paulo – Medical School – Department of Medicine – Ribeirão Preto (SP), Brazil
| | | | - Rogério Serafim Parra
- Universidade de São Paulo – Medical School – Department of Surgery and Anatomy – Ribeirão Preto (SP), Brazil
| | - Marley Ribeiro Feitosa
- Universidade de São Paulo – Medical School – Department of Surgery and Anatomy – Ribeirão Preto (SP), Brazil
| | | | | | - Omar Feres
- Universidade de São Paulo – Medical School – Department of Surgery and Anatomy – Ribeirão Preto (SP), Brazil
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Ramanathan N, Mikulski MF, Perez Coulter AM, Seymour NE, Orthopoulos G. Investigation of optimal hernia repair techniques in patients with inflammatory bowel disease. Surg Endosc 2024; 38:975-982. [PMID: 37968385 DOI: 10.1007/s00464-023-10537-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 10/12/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Multiple laparotomies, immunosuppressive therapy, wound infection, and malnutrition are risk factors for incisional hernia development, which places inflammatory bowel disease (IBD) patients at high risk. With advances in minimally invasive techniques, this study assesses incisional hernia repair techniques and complications in the IBD population. METHODS A single-center, retrospective review of adults with IBD who underwent incisional hernia repair from 2008 to 2022. Complications relative to operative approach and mesh placement location were assessed using descriptive and univariate statistics. RESULTS Eighty-eight IBD patients underwent incisional hernia repair. Fifty-two (59.1%) were on immunomodulators and 30 (34.1%) were repaired primarily. Thirty-five (39.7%) hernias recurred, of whom 19 (33%) had mesh placed. Three (30%) occurred in onlay repairs and 16 (33%) occurred in underlay repairs. Subdivision of underlay repairs into intraperitoneal, preperitoneal and retrorectus mesh placement revealed recurrence rates of 35.1%, 50%, and 14.3%, respectively. Patients with open repair were more likely to have intraoperative bowel injury (28.6% vs 9.7%, p = 0.041) and develop postoperative seromas/abscesses (12.5% vs 0%, p = 0.001) and wound complications (17.9% vs 0%, p = 0.012) compared to laparoscopic. Seromas/abscesses developed more frequently in onlay repairs compared to underlay (40% vs 2.13%, p = 0.001). Twelve (13.6%) patients presented with postoperative small bowel obstruction (SBO), 7 (58.3%) of whom had mesh placed, and 6 (85.7%) were underlay. All SBO after underlay repair had intraperitoneally placed mesh. When comparing surgeons, hernias were more likely to recur performed by colorectal surgeons compared to hernia surgeons (63.3% vs 21.3%, p < 0.001). CONCLUSION In IBD patients, minimally invasive approaches lead to fewer perioperative complications compared to open. Underlay mesh placement demonstrated decreased incidence of seroma/abscess formation compared to onlay. When sub-grouped, underlay placements were similar in terms of complications. Retrorectus placement, however, had fewer recurrences and no readmissions for SBO. This suggests a minimally invasive approach or placement of retrorectus mesh may provide the optimal repair in this patient population.
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Affiliation(s)
- Nikita Ramanathan
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate Medical Center, 759 Chestnut St., Springfield, MA, 01199, USA.
| | - Matthew F Mikulski
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate Medical Center, 759 Chestnut St., Springfield, MA, 01199, USA
| | - Aixa M Perez Coulter
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate Medical Center, 759 Chestnut St., Springfield, MA, 01199, USA
| | - Neal E Seymour
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate Medical Center, 759 Chestnut St., Springfield, MA, 01199, USA
| | - Georgios Orthopoulos
- Department of Surgery, Beth Israel Lahey Health -Winchester Hospital, Boston, USA
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Heise D, Schram C, Eickhoff R, Bednarsch J, Helmedag M, Schmitz SM, Kroh A, Klink CD, Neumann UP, Lambertz A. Incisional hernia repair by synthetic mesh prosthesis in patients with inflammatory bowel disease: a comparative analysis. BMC Surg 2021; 21:353. [PMID: 34579686 PMCID: PMC8474889 DOI: 10.1186/s12893-021-01350-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 09/21/2021] [Indexed: 02/06/2023] Open
Abstract
Background Patients with inflammatory bowel disease (IBD) have a high-life time risk undergoing abdominal surgery and are prone to develop incisional hernias (IH) in the postoperative course. Therefore, we investigated the role of IBD as perioperative risk factor in open ventral hernia repair (OVHR) as well as the impact of IBD on hernia recurrence during postoperative follow-up. Methods The postoperative course of 223 patients (Non-IBD (n = 199) and IBD (n = 34)) who underwent OVHR were compared by means of extensive group comparisons and binary logistic regressions. Hernia recurrence was investigated in the IBD group according to the Kaplan–Meier method and risk factors for recurrence determined by Cox regressions. Results General complications (≥ Clavien-Dindo I) occurred in 30.9% (72/233) and major complications (≥ Clavien-Dindo IIIb) in 7.7% (18/233) of the overall cohort with IBD being the single independent risk-factor for major complications (OR = 4.2, p = 0.007). Further, IBD patients displayed a recurrence rate of 26.5% (9/34) after a median follow-up of 36 months. Multivariable analysis revealed higher rates of recurrence in patients with ulcerative colitis (UC, 8/15, HR = 11.7) compared to patients with Crohn’s disease (CD, 1/19, HR = 1.0, p = 0.021). Conclusion IBD is a significant risk factor for major postoperative morbidity after OVHR. In addition, individuals with IBD show high rates of hernia recurrence over time with UC patients being more prone to recurrence than patients with CD.
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Affiliation(s)
- Daniel Heise
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Charles Schram
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Roman Eickhoff
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Jan Bednarsch
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Marius Helmedag
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Sophia M Schmitz
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Andreas Kroh
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Christian Daniel Klink
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Ulf Peter Neumann
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Andreas Lambertz
- Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
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Magro F, Cordeiro G, Dias AM, Estevinho MM. Inflammatory Bowel Disease - Non-biological treatment. Pharmacol Res 2020; 160:105075. [PMID: 32653651 DOI: 10.1016/j.phrs.2020.105075] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 12/15/2022]
Abstract
Nowadays, non-biological treatments remain valuable approaches among the therapeutic armamentarium of inflammatory bowel disease (IBD). Mesalamine is the core treatment of mild‑to‑moderate ulcerative colitis (UC) and corticosteroids are crucial for the induction of remission of moderate‑to‑severe flares in both UC and Crohn's disease (CD). Even approaches as cyclosporine, tacrolimus, azathioprine, methotrexate, and surgery still have a nuclear position as strategies to induce and/or maintain remission in IBD. Due to their particularities and to the accumulated evidence, each of these strategies conquered peculiar roles in the overall IBD strategy, all of them contributing to better outcomes. This review emphasizes the particular roles that non-biological treatments gained over time: recent mesalamine formulations to increase adhesion rates, higher doses of 5-ASA for high-risk patients, MMX technology to improve drug release and attain higher bowel concentrations, cyclosporine as a bridge to vedolizumab, tacrolimus as a potential alternative to thiopurines or infliximab, azathioprine in combination therapy with infliximab and dubious in monotherapy, and surgery as a mean to a "better end".
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Affiliation(s)
- Fernando Magro
- Clinical Pharmacology Unit, São João Hospital University Centre, Porto, Portugal; Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; Service of Gastroenterology, São João Hospital University Centre, Porto, Portugal.
| | - Gonçalo Cordeiro
- Clinical Pharmacology Unit, São João Hospital University Centre, Porto, Portugal
| | - Andreia Martins Dias
- Clinical Pharmacology Unit, São João Hospital University Centre, Porto, Portugal
| | - Maria Manuela Estevinho
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Alvimopan for the Prevention of Postoperative Ileus in Inflammatory Bowel Disease Patients. Dig Dis Sci 2020; 65:1164-1171. [PMID: 31522323 DOI: 10.1007/s10620-019-05839-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/10/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Postoperative ileus (POI) is a temporary delay of coordinated intestinal peristalsis. Alvimopan, an oral peripherally acting mu-opioid receptor antagonist approved for accelerating gastrointestinal recovery, has never been studied specifically in patients with inflammatory bowel disease (IBD). AIM To investigate the efficacy of alvimopan in preventing POI among IBD patients. METHODS A retrospective chart review was conducted on 246 IBD patients undergoing bowel surgery between 2012 and 2017. Data collected included demographics, IBD subtype, length of stay (LOS), postoperative gastrointestinal symptoms, and administration of alvimopan. The primary outcome was POI; secondary gastrointestinal recovery outcomes were: time to first flatus, time to first bowel movement, time to tolerating a liquid diet, time to tolerating solid food, and LOS. RESULTS When compared with the control group, patients in the alvimopan group had shorter times to tolerating liquids and solids, first flatus, and first bowel movements (p < 0.01). LOS was shorter in the alvimopan group when compared with controls (p < 0.01). The overall incidence of POI was higher in controls than in the alvimopan group (p = 0.07). For laparoscopic surgeries, the incidence of POI was also higher in controls than in the alvimopan group (p < 0.01). On multivariable analysis, alvimopan significantly decreased time to all gastrointestinal recovery endpoints when compared to controls (p < 0.01). CONCLUSIONS Alvimopan is effective in accelerating time to gastrointestinal recovery and reducing POI in IBD patients. While the benefits of alvimopan have been demonstrated previously, this is the first study of the efficacy of alvimopan in IBD patients.
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D'Ugo S, Romano F, Sibio S, Bagaglini G, Sensi B, Biancone L, Monteleone G, Sica GS. Impact of surgery on quality of life in Crohn's disease: short- and mid-term follow-up. Updates Surg 2020; 72:773-780. [PMID: 32185677 DOI: 10.1007/s13304-020-00738-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 03/04/2020] [Indexed: 02/06/2023]
Abstract
Active Crohn's disease has a substantial impact on Quality of Life (QoL). Medical management could be associated to side effects, hospitalization, long treatment period and requires patient's compliance, impacting QoL. Ileocecal resection (ICR) is often required, open or laparoscopic. Aim of the study was to assess Health-Related (HR) QoL changes following ICR, and to identify factors impacting on QoL in the short and mid-term. From a single institution, we created a prospective database of patients undergoing ICR from 01/2009 to 12/2015. HRQoL was analysed with Cleveland Global Quality of Life (CGQL) score, Overall Quality of Happiness (OQH), and asking patients if they would have surgery again. QoL scores were recorded at 30 days, 6, 12 and 36 months postoperatively and compared according to follow-up timing, technique, medical treatment and demographics. Statistical analysis included 187 patients. Mean follow-up was 3.8 ± 2.9 years. Both at 30 days and 6 months postoperatively, CGQL, its items and OQH increased significantly (p < 0.001). Increased values were also recorded at 1 and 3 years; 88% of patients would undergo surgery again. Laparoscopy was associated with improved CGQL scores, while preoperative steroids with worsen data. Young female patients, with penetrating pattern, experienced greater HRQoL improvements. Surgery is associated with improvements of HRQoL and patients' happiness in the short and mid-term. Laparoscopy, steroid-free and young patients showed the best results. ICR should be considered a reasonable alternative to non-operative strategies in selected cases.
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Affiliation(s)
- Stefano D'Ugo
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy.
- Department of Surgery, "Vito Fazzi" Hospital, Piazza F. Muratore, 73100, Lecce, Italy.
| | - Francesca Romano
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Simone Sibio
- Department of Surgery, La Sapienza University, P.le A. Moro, Rome, Italy
| | - Giulia Bagaglini
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Bruno Sensi
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Livia Biancone
- Gastroenterology Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Giovanni Monteleone
- Gastroenterology Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
| | - Giuseppe S Sica
- Gastrointestinal Surgery Unit, Tor Vergata University Hospital, Viale Oxford 81, 00133, Rome, Italy
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Giugliano DN, Bernier GV, Johnson EK. Other Surgeries in Patients with Inflammatory Bowel Disease. Surg Clin North Am 2019; 99:1163-1176. [PMID: 31676055 DOI: 10.1016/j.suc.2019.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patients with inflammatory bowel disease (IBD) will often require abdominal surgical intervention for indications not directly related to their IBD. Because these patients often have a history of multiple previous abdominal operations and/or ostomies, they are at increased risk for incisional and parastomal hernias. They may also have develop symptomatic cholelithiasis, chronic pain, or desmoid disease. All of these potentially surgical issues may require special consideration in the IBD population.
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Affiliation(s)
- Danica N Giugliano
- Cooper University Hospital, Department of Surgery, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA
| | - Greta V Bernier
- UW Medicine- Valley Medical Center, Colorectal Surgery Clinic, 4011 Talbot Road South, #420, Renton, WA 98055, USA
| | - Eric K Johnson
- Cleveland Clinic Colorectal Surgery, 6770 Mayfield Road #348, HC31, Mayfield Heights, OH 44124, USA.
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Incidence and Factors Correlating With Incisional Hernia Following Open Bowel Resection in Patients With Inflammatory Bowel Disease: A Review of 1000 Patients. Ann Surg 2019; 267:532-536. [PMID: 29408835 DOI: 10.1097/sla.0000000000002120] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this study was to identify the incidence and factors associated with the development of incisional hernia (IH) in patients with inflammatory bowel disease (IBD) undergoing open bowel resections. BACKGROUND Predisposing factors for IH have not been well studied in patients with IBD undergoing open bowel resection. The role of duration of the disease, nutritional factors, anti-inflammatory treatment, previous operative procedures, wound infection, and other complicating factors remains unclear. METHODS One thousand patients with ulcerative colitis and Crohn's disease were followed for a mean of 8 years after open bowel resection. The incidence of IH was recorded as well as correlating factors with the development of IH. RESULTS The overall incidence of IH in this series was 20% (21% for ulcerative colitis and 20% for Crohn's disease). Statistically significant risk factors for development of IH were wound infection (HR 3.66, P <0.001), hypoalbuminemia (HR 2.02, P = 0.002), history of previous bowel resection (HR 1.60, P = 0.003), creation of ileostomy at the time of procedure (HR 1.53, P = 0.01), history of smoking (HR 1.52, P = 0.013), body mass index at surgery (1.036, P = 0.009), age at surgery (HR 1.021, P <0.001), and age at the onset of disease (HR 1.018, P <0.001). CONCLUSIONS Patients with IBD have a high incidence of incisional hernia after open bowel resection. Wound infection had the strongest correlation with the development of IH. The other factors were age at onset of IBD, age at surgery, body mass index, serum albumin, presence of ileostomy, previous surgical procedures, and history of smoking. Duration of disease, preoperative steroids, immunosuppressive therapy, and blood transfusion were not found to correlate with IH.
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Yamamoto-Furusho J, Gutiérrez-Grobe Y, López-Gómez J, Bosques-Padilla F, Rocha-Ramírez J. The Mexican consensus on the diagnosis and treatment of ulcerative colitis. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018. [DOI: 10.1016/j.rgmxen.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Consenso mexicano para el diagnóstico y tratamiento de la colitis ulcerosa crónica idiopática. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:144-167. [DOI: 10.1016/j.rgmx.2017.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/15/2017] [Accepted: 08/29/2017] [Indexed: 12/15/2022]
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TSPO PET Imaging: From Microglial Activation to Peripheral Sterile Inflammatory Diseases? CONTRAST MEDIA & MOLECULAR IMAGING 2017; 2017:6592139. [PMID: 29114179 PMCID: PMC5632884 DOI: 10.1155/2017/6592139] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/01/2017] [Accepted: 08/07/2017] [Indexed: 02/07/2023]
Abstract
Peripheral sterile inflammatory diseases (PSIDs) are a heterogeneous group of disorders that gathers several chronic insults involving the cardiovascular, respiratory, gastrointestinal, or musculoskeletal system and wherein inflammation is the cornerstone of the pathophysiology. In PSID, timely characterization and localization of inflammatory foci are crucial for an adequate care for patients. In brain diseases, in vivo positron emission tomography (PET) exploration of inflammation has matured over the last 20 years, through the development of radiopharmaceuticals targeting the translocator protein-18 kDa (TSPO) as molecular biomarkers of activated microglia. Recently, TSPO has been introduced as a possible molecular target for PSIDs PET imaging, making this protein a potential biomarker to address disease heterogeneity, to assist in patient stratification, and to contribute to predicting treatment response. In this review, we summarized the major research advances recently made in the field of TSPO PET imaging in PSIDs. Promising preliminary results have been reported in bowel, cardiovascular, and rheumatic inflammatory diseases, consolidated by preclinical studies. Limitations of TSPO PET imaging in PSIDs, regarding both its large expression in healthy peripheral tissues, unlike in central nervous system, and the production of peripheral radiolabeled metabolites, are also discussed, regarding their possible consequences on TSPO PET signal's quantification.
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