Surgical Management of Hemorrhoidal Disease in Inflammatory Bowel Disease: A Systematic Review with Proportional Meta-Analysis

Surgical treatment of hemorrhoidal disease (HD) in inflammatory bowel disease (IBD) has been considered to be potentially harmful, but the evidence for this is poor. Therefore, a systematic review of the literature was undertaken to reappraise the safety and effectiveness of surgical treatments in this special circumstance. A MEDLINE, Web of Science, Scopus, and Cochrane Library search was performed to retrieve studies reporting the outcomes of surgical treatment of HD in patients with Crohn's disease (CD) and ulcerative colitis (UC). From a total of 2072 citations, 10 retrospective studies including 222 (range, 2-70) patients were identified. Of these, 119 (54%) had CD and 103 (46%) UC. Mean age was between 41 and 49 years (range 14-77). Most studies lacked information on the interval between surgery and the onset of complications. Operative treatments included open or closed hemorrhoidectomy (n = 156 patients (70%)), rubber band ligation (n = 39 (18%)), excision or incision of thrombosed hemorrhoid (n = 14 (6%)), and doppler-guided hemorrhoidal artery ligation (DG-HAL, n = 13 (6%)). In total, 23 patients developed a complication (pooled prevalence, 9%; (95%CI, 3-16%)), with a more than two-fold higher rate in patients with CD compared to UC (11% (5-16%) vs. 5% (0-13%), respectively). Despite the low quality evidence, surgical management of HD in IBD and particularly in CD patients who have failed nonoperative therapy should still be performed with caution and limited to inactive disease. Further studies should determine whether advantages in terms of safety and effectiveness with the use of non-excisional techniques (e.g., DG-HAL) can be obtained in this patient population.

Laparoscopic Right Colectomy. Intracorporeal Anastomosis Is Associated with Better Outcome

Colon cancer is the third most common cancer in man and woman in the developed world. Laparoscopic right colectomy is the standard of care for right colon cancer. Since the first report on laparoscopic approach in 1991, the surgical technique has been improved and currently all procedure is performed intracorporeally. The ileo-colic anastomosis can be performed either intracorporeal and extracorporeal: the differences in clinical outcome, complications rate, hospital stay and quality of life between that two techniques are not still clear and a large number of studies has been published about that. According to most recent meta-analysis, intracorporeal anastomosis have showed better outcome in anastomotic leakage rate, surgical site infection rate, development of incisional hernia, postoperative pain and recovery of gastrointestinal function.

Tumor cells induce platelet aggregation and intraplatelet calcium ion movements

We studied platelet aggregation and changes in cytosolic Ca(++) concentrations induced by cells isolated from 5 human tumor tissues (2 hepatocellular carcinomas, 1 colon carcinoma, 1 gastric carcinoma and 1 pancreatic carcinoma). A Platelet Ionized Calcium Aggregometer was used and washed, aequorin loaded platelets were employed. Tumor cells were able to induce aggregation and an increase in cytoplasmic Ca(++) concentrations in the presence of trace amounts (10 µl) of PPP, while no aggregating response was found after addition of fibrinogen alone to washed platelets. The platelet aggregating activity of tumor cells was maintained in the presence of factor VII deficient plasma or of factor VIII deficient plasma, and disappeared completely when factor X deficient plasma was added to washed platelets. Furthermore, tumor cell induced platelet aggregation and Ca (++) movements were inhibited by hirudin (100 U/ml), a specific thrombin inhibitor, while concanavalin A (100 µg/ml), a tissue factor inhibitor, had no effect. Finally, preincubation of neoplastic cells with HgCl(2) (0.5 mM), a cysteine protease inhibitor, markedly decreased their ability to induce aggregation and Ca(++) movements; on the contrary, incubation of cells with soybean trypsin inhibitor (10 µg/ml), a serine protease inhibitor, or with concanavalin A (100 µg/ml) had no effect. These data suggest that cells isolated from human tumor tissues activate platelet function through the generation of thrombin, due to a cysteine protease which directly activates factor X.

[Levels of different metabolites of arachidonic acid in synovial fluid of patients with arthrosis or rheumatoid arthritis]

OBJECTIVE

Clinical and experimental evidence suggests that arachidonic acid metabolism through lipoxygenase and cyclooxygenase pathways may play an important role in the pathogenesis of both inflammatory and degenerative joint diseases. The aim of the present paper was to measure the levels of different arachidonate metabolites in arthrosis or rheumatoid joint effusions.

MATERIALS AND METHODS

We studied synovial fluids from 22 patients with arthrosis and 8 patients with rheumatoid arthritis. The levels of TxB2, 6-keto-PGF1 alpha LTB4 and LTC4 were measured by radioimmunoassay.

RESULTS

The levels of the different arachidonate metabolites were higher in patients with rheumatoid arthritis than in those with arthrosis and the differences were always statistically significant, except for TxB2 values. Furthermore, in patients with arthrosis the levels of such metabolites were not significantly correlated with one another, with the exception of LTB4 and LTC4 values, while in patients with rheumatoid arthritis these levels were directly and significantly correlated.

CONCLUSIONS

In inflammatory joint disease levels of arachidonate metabolites are higher and more directly correlated with one another than in degenerative joint disease. Our data may explain the better efficacy of non-steroidal anti-inflammatory drugs in patients with arthrosis than in those with rheumatoid arthritis and the frequent necessity for steroidal treatment in this last condition.

Current concepts in coronary thrombolysis

Thrombolytic therapy has become standard care in treating acute myocardial infarction. Fibrinolytic drugs such as streptokinase, APSAC and urokinase are non fibrin specific, and induce systemic activation of the fibrinolytic process, while t-PA and prourokinase are fibrin specific since they are able to activate mainly fibrin bound plasminogen. Both groups of thrombolytics exert different and opposing effects on the hemostatic balance: indeed, they have antithrombotic as well as prothrombotic properties, and this may be important for explaining therapeutic failures or reocclusions. New strategies have been considered or are under investigation for further improving the already excellent efficacy of thrombolytic treatment in myocardial infarction: combined administration of fibrinolytic agents, thrombus-targeted thrombolytic drugs, association with other drugs both effective and ineffective on the hemostatic process. At present, however, the first priority still seems to be a continuing effort to increase the percentage of patients treated with thrombolytics, since the benefits of this therapy have already been clearly demonstrated.

Effect of interferon alpha, interferon gamma and tumor necrosis factor on the procoagulant activity of human cancer cells

BACKGROUND

It is not known whether the different cytokines may influence the procoagulant activity of cancer cells; the purpose of this study was to investigate the effect of interferon alpha, interferon gamma and tumor necrosis factor on the procoagulation capacity of human cancer cells cultured "in vitro" or isolated from tumor tissues.

METHODS

"In vitro" cultured tumor cell lines were derived from a patient with malignant mesothelioma and a patient with lung adenocarcinoma. Cells isolated from 6 carcinomas of different origin were also investigated. The procoagulant activity of the cells before and after treatment with the cytokines was expressed as RBT U/10(5) cells or RVV U/10(5) cells.

RESULTS

Short-term incubation of tumor cells cultured "in vitro" with cytokines did not modify their procoagulant activity; after longer incubation however, interferon alpha induced a significant increase in the procoagulant activity of mesothelioma cells, while interferon gamma induced and increase in the procoagulant activity of lung adenocarcinoma cells. Furthermore, short-term incubation of cells isolated from tumor tissues with interferon gamma or tumor necrosis factor resulted in a significant increase of procoagulant activity, while interferon alpha had no effect.

CONCLUSIONS

Altogether, these data demonstrate that the cytokines may influence the expression of the different procoagulant activities of tumor cells.

Different expression of procoagulant activity in human cancer cells cultured "in vitro" or in cells isolated from human tumor tissues

We studied in a homologous system the procoagulant activity of human tumor cells cultured "in vitro" (1402 primary melanoma, Me 7110/2 metastatic melanoma, Hep G2 hepatoma and GLC1 small cell lung carcinoma) or of cells freshly isolated from different human tumor tissues. Tumor cells cultured "in vitro" possessed and released a factor VII dependent procoagulant activity, which was inhibited by concanavalin A and unaffected by iodoacetamide or HgCl2. The activity released by the cells of metastatic melanoma was higher than that released by the cells of the primary tumor. On the contrary, cancer cells isolated from tumor tissues possessed and released a factor VII independent activity which was inhibited by iodoacetamide of HgCl2 and was not modified by concanavalin A. Therefore, different methods for the preparation of tumor cell suspensions have to be used for the study of tumor procoagulants, since their expression depends very largely on the source of tumor cells. Furthermore, cultured human tumor cells are not an appropriate model for the "in vivo" procoagulant effect of tumor cells.

Antithrombin III biological activity and emotional stress in patients with coronary artery disease

We studied the effect of emotional stress (mental arithmetic for 10 minutes) in ten postinfarction patients and in ten age-matched, apparently healthy subjects as controls. Blood samples for the determination of epinephrine and AT III levels were taken in basal conditions, at the end of mental stress and after 30 minutes of recovery. Mental stress induced a significant increase in epinephrine levels and a significant decrease in AT III levels in control subjects. Both parameters returned to baseline values after 30 minutes of recovery. On the contrary, in postinfarction patients AT III levels of recovery were still significantly lower than those of baseline, suggesting a reduced ability to restore the original concentration of this physiologic inhibitor. Our data can contribute to a better understanding of the complex relationships among phychosocial factors, the haemostatic system and vascular disease.

Effect of mental stress on platelet function in normal subjects and in patients with coronary artery disease

We studied the effect of emotional stress (mental arithmetic for 10 min) in 10 postinfarction patients and in 10 age-matched apparently healthy subjects as controls. Blood samples for platelet function studies and for the determination of epinephrine levels in serum were taken in basal conditions, at the end of mental stress and after 30 min of recovery. Patients were studied twice, in washout of medications and after oral administration of dipyridamole, 200 mg twice a day for 6 consecutive days. Mental stress induced in patients significant increments in different hemodynamic parameters (heart rate, systolic blood pressure and diastolic blood pressure) and in serum epinephrine levels. Concomitantly, the test produced a significant increase in platelet aggregation (induced by 3 microM ADP or 1 microgram/ml collagen), the formation of circulating platelet aggregates and an increase in plasma thromboxane B2 levels. Hemodynamic parameters and platelet function tests returned to baseline values after 30 min. Similar activation of hemodynamic parameters, similar increase in epinephrine levels and lower increase in platelet function by emotional stress were observed in control subjects. Treatment of patients with dipyridamole had no effect on stress-induced increase in hemodynamic parameters and epinephrine levels, but decreased stress-related platelet activation. These data can contribute to a better understanding of the complex relationships between psychosocial factors, the hemostatic system and vascular disease.

Proaggregating and procoagulant activities of human mesothelioma tumor cells at different stages of "in vitro" culture

BACKGROUND

The mechanisms of the interactions between tumor cells and the hemostatic system are not completely understood; the purpose of this study was to elucidate whether tumor cells grown "in vitro" express the same proaggregating and procoagulant activities as cells isolated from tumor tissues, and whether the activities of such cultures are constant and consistent over time.

METHODS

Tumor cells were collected and cultured from the pleural fluid of a 71-year-old patient with a sarcomatous malignant mesothelioma. Platelet aggregating activity was studied by adding tumor cells to platelet rich plasma or to washed, aequorin-loaded platelets. The procoagulant activity of the tumor cells was measured by the one-stage recalcification time of different humans plasma substrates.

RESULTS

Cells harvested after 4 culture passages possessed low, ADP-dependent platelet aggregating activity, while those studied after 16 or 40 passages activated platelets through the production of thrombin. In the washed platelet system and in the presence of trace amounts of platelet poor plasma, the difference in the aggregating activity of various tumor cell populations was more evident. Normal mesothelial cells did not induce platelet aggregation. Procoagulant activity (tissue factor-like) was low in normal mesothelial cells and in tumor cells after 4 passages, and it was about 10 times higher in tumor cells after 16 or 40 passages.

CONCLUSIONS

Results obtained with tumor cells cultured "in vitro" should be considered with caution because their effects are different from those of freshly isolated cells and may not be constant in the different culture passages.

Platelet activation by emotional stress in patients with coronary artery disease

We studied the effects of experimentally induced emotional stress (mental arithmetic) on different hemodynamic parameters, catecholamine levels, and serum and platelet function tests in 25 postinfarction patients and in 10 apparently healthy, age-matched control subjects. Mental stress (10 minutes) induced significant increments in heart rate, systolic blood pressure, diastolic blood pressure, double product, and cardiac output, indicating a sympatho-adrenal stimulation that was confirmed by a significant increase in serum epinephrine and norepinephrine levels. All of the effects disappeared at minute 10 of recovery. Concomitantly, the test produced a significant increase in platelet aggregation (induced by 3 microM ADP or 1 microgram/ml collagen), the formation of circulating platelet aggregates, and an increase in thromboxane B2 levels in plasma and serum. These effects were also rapidly reversible. Similar activation of hemodynamic parameters and a similar but less evident increase in platelet function by emotional stress were observed in control subjects. A possible artifact due to factitious platelet activation by catheter sampling was excluded with experiments in which a 40-minute rest was introduced after the baseline period and before mental stress; platelet activation did not occur during baseline or rest periods, only after emotional stress. Furthermore, the antiplatelet drug dipyridamole reduced the stress-induced formation of platelet aggregates in postinfarction patients. These results demonstrate the existence of a direct link between emotional stress and platelet function and offer an explanation of one of the mechanisms through which mental stress may be involved in the development of coronary artery disease.

Human tumor cells cultured "in vitro" activate platelet function by producing ADP or thrombin

We studied the effects on platelet function of different human tumour cells cultured "in vitro": Mo T lymphocyte cell line, NCI-N592 small cell lung carcinoma cell line, and 5637 bladder carcinoma cell line. Mo and NCI-N592 cells possessed a slight, dose-dependent platelet aggregating activity, which was completely abolished by apyrase and unaffected by hirudin. The cell-free supernatant also induced an aggregation response, which was very similar to that obtained with tumour cell suspensions. The presence of ADP in the cell-free supernatants of cell suspensions was confirmed by HPLC analysis. On the contrary, aggregation induced by 5637 cells was preceded by a significant lag phase; it was not affected by apyrase but it was abolished by hirudin, and the cell-free supernatant had no effect. These data suggest that Mo and NCI-N592 cells activate platelets by producing ADP, while 5637 cells stimulate platelet function by generating thrombin. The amount of ADP produced by the first two tumour cell lines was measured by bioassay: the extent of such production was similar for both cell lines and the maximum was reached after 60 minutes and maintained for up to 3 hours. These results suggest that neoplastic cells can activate platelets by different mechanisms: such investigations should be performed in homologous systems and in well-defined experimental conditions.

Fibrinopeptide A levels in patients with acute ischaemic heart disease

Fibrinopeptide A (FPA) levels were determined in 40 consecutive patients admitted to the coronary care unit with a typical history of chest pain: in 24 of them a diagnosis of acute myocardial infarction (AMI) and in 16 a diagnosis of angina was made. Seven of the patients with AMI suffered from recurrent episodes of early post-infarctional angina. FPA levels were determined in each patient on admission and every 4 h for 48 h. On admission in patients with both angina and AMI the FPA levels were significantly higher than in normal controls; these levels were higher in patients with AMI than in those with angina, but this difference was not significant. In patients with angina the values decreased progressively after 12 h to baseline values, while in those with AMI the high levels of FPA persisted throughout the 48-hour observation period. In many instances, particularly after 24 h, the differences between the two groups were statistically significant. In patients with early post-infarctional angina the episode of angor was preceded by or corresponded to a new great elevation of FPA levels. These data suggest that the thrombin generation is higher and more prolonged in patients with AMI than in those with angina; the determination of FPA levels, which are an index of 'in vivo' thrombin generation, can be useful to follow the clinical course of ischaemic heart disease.

Human breast and colon carcinomas express cysteine proteinase activities with pro-aggregating and pro-coagulant properties

We have investigated concomitantly the pro-aggregating and pro-coagulant activities of 11 breast and 2 colon human carcinomas. Tumor tissues, obtained at surgery, were immediately processed to prepare tumor-cell suspensions for the study of aggregating activity and tissue extracts for the study of procoagulant capacity. Nine carcinomas (8 breast and 1 colon) possessed a high, dose-dependent platelet-aggregating activity, which was present in the cell-free supernatant and was inhibited by HgCl2 and iodoacetic acid, specific cysteine proteinase inhibitors, while apyrase and hirudin had no significant effect; in contrast, the other tumors did not aggregate platelets. All the tumor extracts tested from 12 carcinomas (11 breast and 1 colon) were able to activate blood coagulation in both the presence and the absence of F VII. The activity was inhibited by HgCl2 and iodoacetamide, while Con A was less effective. Therefore, these tumors do not aggregate platelets through the production of ADP or thrombin, nor promote blood coagulation through the production and release of tissue factor; a tumor-associated cysteine proteinase plays a major role in both pro-aggregating and pro-coagulant activities.