Quality of life in ulcerative colitis patients treated medically versus patients undergoing surgery

OBJECTIVES

Approximately one third of patients with ulcerative colitis (UC) require surgery.

AIM

Aim of this study was to assess the quality of life (QoL) of UC patients who have undergone surgery with ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) compared to UC patients not operated.

PATIENTS AND METHODS

Fifty consecutive UC patients for each group observed between 1988-2010 were included. To all patients was administered a self completed questionnaire with four different scores: intestinal symptoms (IS), systemic symptoms (SS), emotional function (EF), social function (SF) and an overall QoL score.

RESULTS

Overall QoL score and three dimensions (SS, EF, SF) resulted not significantly different in the three groups, except for IS that resulted worst in the IRA-Group. According to the activity of disease it appeared that UC and IRA patients with mild activity had an overall QoL score similar to patients with complicated IPAA. A higher statistically different score of overall QoL was observed in patients with UC and IRA with moderate/severe disease.

CONCLUSIONS

Results of the study demonstrate that overall QoL score is poorer in patients with UC and IRA with mild activity and in patients with complicated IPAA and is worst in patients with UC and IRA with moderate/severe activity.

TGF-beta1 production in inflammatory bowel disease: differing production patterns in Crohn's disease and ulcerative colitis

Transforming growth factor-beta (TGF-beta) is an inhibitory cytokine recognized as a key regulator of immunological homeostasis and inflammatory responses. TGF-beta is involved in experimental models of oral tolerance and in the pathogenesis of experimental colitis. Patients with inflammatory bowel disease (IBD) have inappropriate T cell responses to antigenic components of their own intestinal microflora, suggesting the presence of a disorder in the normal mucosal immune mechanism that ensures the down-regulation of responses to harmless constituents in the microflora. To evaluate the contribution of TGF-beta to this imbalance, we measured TGF-beta1 production by lamina propria mononuclear cells (LPMC) and T cells isolated from tissue specimens of patients with Crohn's disease (CD), ulcerative colitis (UC) and controls. Cells were cultured in the presence or absence of anti-CD2 plus anti-CD28 MoAbs and TGF-beta1 production in culture supernatants was measured by ELISA. LPMC isolated from CD patients produced significantly less TGF-beta1 than controls when stimulated via CD2 plus CD28 pathways (P = 0.001)] conversely, in UC patients increased production of TGF-beta1 compared to controls was observed (P = 0.0005). These differences were also observed with purified lamina propria (LP) T cells in both diseases and were associated with the presence of inflammation. Thus, TGF-beta1 production shows contrasting secretion in CD and in UC, probably as a consequence of the different Th polarization. The absolute or relative defect in TGF-beta1 production observed in CD and UC may contribute to the perpetuation of inflammation.

Use of autologous blood in general surgery

BACKGROUND/AIMS

Autologous blood predonation is still not as widespread as it should be in general surgery practice, even if the method is well-known and has benefits established in international literature. Authors describe the impact of an autotransfusion program, in a general surgery university department, focusing on management and cost problems.

METHODOLOGY

A description of the efficacy of the program during a yearlong activity period is presented. An analysis has been made about the quantity of predonated blood/plasma units, the quantity actually transfused and use of homologous blood. The problems which occurred and the cost are discussed.

RESULTS

The most used autotransfusion method was preoperative predeposit of autologous blood. The analysis of results focused on some organizational problems that need to be avoided in order to show the methods maximum benefits. In a large number of cases (some 50%) predeposit was not made because of several managing/technical problems. In another large number of cases (38%) the quantity of units predonated did not fully supply the needs and several patients received homologous products. In another number of cases predonated blood units were not used at all (61/34%).

CONCLUSIONS

Predeposit, preoperative hemodilution and intraoperative recovery, are methods that should all be available in a general surgery department to manage in the best way the single patients blood/plasma needs, reducing post-transfusion complication. To optimize the program and minimize waste some guidelines must be established, with the aim of a rational and correct use of the procedure. Despite the value of the method, and the favor encountered by the patients, we must not forget that the use of autologous blood is not costless.

[The extempore intraoperative cytology of peritoneal lavage fluid. A study of the reliability of the method]

Data are presented about a 100 cases prospective study, designed to evaluate sensibility/specificity of intra-operative cytology on peritoneal washing in case of cancer of digestive tract. Data analysis showed a very low sensibility of the test (according with most of literature observations) that does not allow to consider it fully reliable. Authors, thus, suggest a critical use of the test and state doubts about his real value in the intra-operative correct managing of therapeutic options.

[Gastrointestinal stromal tumors: clinical and instrumental diagnosis. Analysis of a review of the literature]

AIM

From a personal experience of 23 treated gastrointestinal stromal tumor (GISTs), this study analyzed both clinical and diagnostic problems of this quite new nosological category.

MATERIALS AND METHODS

A this literature review provides a rigid selection of papers (scientific basis, statistic inference, type/quality of the journal, etc.); only numerous series have been included (case reports were excluded) and only those published after 1990. Three-hundred-seventy-five cases have therefore been selected. Starting and late symptoms/signs and diagnostic tests employed were analyzed.

RESULTS

Results show 1) a relevant GIST quantity (approx. 30%) is casually discovered, during operations carried out for other pathologies or diagnostic tests for other indications; 2) poor correlation between site of the tumor and clinical manifestations; 3) a positive correlation between tumor diameter and presence of symptoms/signs seems to exists. The accuracy of different diagnostic tests is reported.

CONCLUSION

No specific symptoms/signs have been isolated; this kind of tumor is often accidentally found. An analysis of different diagnostic tests available today shows the very important role of endoscopic ultra-sound, together with CT and MRI.

Lamina propria T cells in Crohn's disease and other gastrointestinal inflammation show defective CD2 pathway-induced apoptosis

BACKGROUND & AIMS

Normal human lamina propria lymphocytes manifest increased unstimulated apoptosis compared with peripheral lymphocytes, which are enhanced after stimulation via the CD2 activation pathway. This activation-induced apoptosis down-regulates cell expansion and cytokine production. In previous studies, it was shown that lamina propria T cells from patients with Crohn's disease and ulcerative colitis manifest abnormal proliferation and cytokine production. It was therefore of interest to determine if such cells also showed abnormal patterns of apoptosis.

METHODS

Apoptosis was evaluated by propidium iodide staining of cells followed by flow cytometric analysis. Fas expression and Bcl-2 levels in cells were evaluated by immunofluorescence.

RESULTS

Lamina propria lymphocytes from patients with Crohn's disease and ulcerative colitis as well as from 2 patients with diverticulitis showed defective CD2 pathway-induced apoptosis. Studies of the mechanisms of this defect focusing on cells from patients with Crohn's disease showed that Crohn's disease lamina propria lymphocytes from inflamed tissues express the same amount of cell surface Fas but are less sensitive to Fas-mediated apoptosis than control cells. In addition, lamina propria lymphocytes from inflamed Crohn's disease tissues manifest increased expression of Bcl-2 after CD2 pathway stimulation and elevated Bcl-2 levels in cultures of unstimulated T cells.

CONCLUSIONS

T cells isolated from areas of inflammation in Crohn's disease, ulcerative colitis, and other inflammatory states manifest decreased CD2 pathway-induced apoptosis. Studies of cells from inflamed Crohn's disease tissue indicate that this defect is accompanied by elevated Bcl-2 levels. These changes are probably caused by the chronic inflammation and may aggravate the underlying disease processes that are present.

HIV-1 gp120 accelerates Fas-mediated activation-induced human lamina propria T cell apoptosis

Intestinal mucosa represents an important portal of entry of HIV and a site of virus reservoir and active replication. Recently, in HIV patients, an early depletion of intestinal lamina propria T lymphocytes (LPT) has been described. HIV-1 gp120 has been demonstrated to promote apoptosis in noninfected isolated peripheral blood T cells, therefore we investigated whether gpl20 modulates apoptosis of normal human intestinal lamina propria T cells. Purified T cells were obtained by immunomagnetic negative selection from human lamina propria mononuclear cells isolated from surgical specimens by enzymatic procedure. Cells were incubated with or without recombinant gpl20 (10 microg/ml) and cultured either in the absence of any stimulus or in the presence of plate-bound anti-CD3 Ab (OKT3) or soluble anti-CD2 Ab (T11(2) + T11[3]). Apoptosis was assessed by flow cytometric analysis after propidium iodide staining. We demonstrated that preincubation of normal LPT cells with HIV-1 gpl20 accelerates the apoptosis observed during CD2-pathway stimulation of LPT cells. This process is mediated by Fas/Fas ligand interaction and related to an increased induction of Fas ligand mRNA by gpl20. Therefore HIV-1 gp120 could contribute to the depletion of noninfected LPT cells inducing a premature cell death.

Image analysis in multisample biopsy after ileal pouch-anal anastomosis

Pouchitis in ileal anal anastomosis represents an important clinical complication after restorative proctocolectomy. Acute and chronic inflammation of the reservoir is a frequent event sometimes associated with villous atrophy and colonic metaplasia. After ileal pouch anastomosis, twenty-one patients affected by ulcerative colitis were studied. An image analyzer CAS 200 (Becton Dickinson) was utilized to evaluate the DNA intranuclear content in every biopsy. In two cases abnormal DNA distribution was observed, and in one case a poliploid pattern was seen. Abnormal DNA distribution was also present in colonic metaplasia. Therefore, image analysis for the detection of DNA aneuploidy may be of additional value together with histologic parameters in follow up, in order to exclude transformation of the ileal mucosa in neoplastic epithelia.

[Locoregional staging of cancer of the rectum with transrectal echography]

Accurate preoperative staging of rectal cancer is very important for both prognosis and the choice of surgical approach. The authors report the results obtained by means of endorectal US in the locoregional staging of medium-low rectal neoplasms. The TNM UICC 1988 classification was considered as reference. US findings were compared with histologic results. Thirty-seven patients with rectal cancer were studied with endorectal US; they had been selected on the basis of rectal examination findings, of combined endoscopy and biopsy, and barium enema results. US was performed only when the lesion was confined within 13 cm from the anal edge. US and histologic findings were compared in 32 of 37 patients; in 2 cases surgery could not be performed, and 3 patients could not undergo US due to the presence of a tight rectal stenosis. Overall US sensitivity was 87.5%. T1 (2 cases) and T4 (2 cases) staging was always correct; 2 of 16 patients were understaged as T2 (T3), while 2 of 12 were overstaged as T3 (T2). In conclusion, endorectal US appears to be an accurate method for the locoregional staging of rectal cancer.