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Crispino F, Michielan A, Grova M, Tieppo C, Mazza M, Rogger TM, Armelao F. Exit strategies in inflammatory bowel disease: Looking beyond anti-tumor necrosis factors. World J Clin Cases 2023; 11:2657-2669. [PMID: 37214561 PMCID: PMC10198103 DOI: 10.12998/wjcc.v11.i12.2657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
The long-term management of patients with inflammatory bowel disease (IBD) is still a matter of debate, and no clear guidelines have been issued. In clinical practice, gastroenterologists often have to deal with patients in prolonged remission after immunomodulatory or immunosuppressive therapies. When planning an exit strategy for drug withdrawal, the risk of disease relapse must be balanced against the risk of drug-related adverse events and healthcare costs. Furthermore, there is still a dearth of data on the withdrawal of novel biologics, such as the anti-α4β7 integrin antibody (vedolizumab) and anti-IL12/23 antibody (ustekinumab), as well as the small molecule tofacitinib. Models for estimating the risk of disease relapse and the efficacy of retreatment should be evaluated according to the patient's age and IBD phenotype. These models should guide clinicians in programming a temporary drug withdrawal after discussing realistic outcomes with the patient. This would shift the paradigm from an exit strategy to a holiday strategy.
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Affiliation(s)
- Federica Crispino
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Andrea Michielan
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Mauro Grova
- Inflammatory Bowel Disease Unit, Department of Medicine, Azienda Ospedaliera Ospedali Riuniti, Villa Sofia-Cervello, Palermo 90146, Italy
| | - Chiara Tieppo
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Marta Mazza
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Teresa Marzia Rogger
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Franco Armelao
- Azienda Provinciale per i Servizi Sanitari, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
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Michielan A, Merola E, Vieceli F, Rogger TM, Crispino F, Sartori C, Decarli NL, de Pretis G, de Pretis N. Recurrence rates after piecemeal endoscopic mucosal resection of large colorectal laterally spreading tumors. Ann Gastroenterol 2023; 36:195-202. [PMID: 36864943 PMCID: PMC9932858 DOI: 10.20524/aog.2023.0774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/02/2023] [Indexed: 02/05/2023] Open
Abstract
Background Piecemeal endoscopic mucosal resection (pEMR) is routinely employed for large laterally spreading tumors (LSTs). Recurrence rates following pEMR are still unclear, especially when cap-assisted EMR (EMR-c) is performed. We assessed the recurrence rates and recurrence risk factors post-pEMR for large colorectal LSTs, including both wide-field EMR (WF-EMR) and EMR-c. Methods This was a single-center, retrospective study of consecutive patients who underwent pEMR for colorectal LSTs ≥20 mm at our institution between 2012 and 2020. Patients had a post-resection follow-up period of at least 3 months. A risk factor analysis was carried out using the Cox regression model. Results The analysis included 155 pEMR: 51 WF-EMR and 104 EMR-c, with a median lesion size of 30 (range: 20-80) mm and a median endoscopic follow up of 15 (range: 3-76) months. Overall, disease recurrence occurred in 29.0% of cases; there was no significant difference in recurrence rates between WF-EMR and EMR-c. Recurrent lesions were safely managed by endoscopic removal, and at risk analysis lesion size was the only significant risk factor for recurrence (mm; hazard ratio 1.03, 95% confidence interval 1.00-1.06, P=0.02). Conclusions Recurrence of large colorectal LSTs after pEMR occurs in 29% of cases. This rate is mainly dependent on lesion size, and the use of a cap during pEMR has no effect on recurrence. Prospective controlled trials are needed to validate these results.
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Affiliation(s)
- Andrea Michielan
- Gastroenterology and Digestive Endoscopy Unit, Department of Surgery, Santa Chiara Hospital, Trento (Andrea Michielan, Elettra Merola, Filippo Vieceli, Teresa Marzia Rogger, Federica Crispino, Giovanni de Pretis, Nicolò de Pretis)
| | - Elettra Merola
- Gastroenterology and Digestive Endoscopy Unit, Department of Surgery, Santa Chiara Hospital, Trento (Andrea Michielan, Elettra Merola, Filippo Vieceli, Teresa Marzia Rogger, Federica Crispino, Giovanni de Pretis, Nicolò de Pretis)
| | - Filippo Vieceli
- Gastroenterology and Digestive Endoscopy Unit, Department of Surgery, Santa Chiara Hospital, Trento (Andrea Michielan, Elettra Merola, Filippo Vieceli, Teresa Marzia Rogger, Federica Crispino, Giovanni de Pretis, Nicolò de Pretis)
| | - Teresa Marzia Rogger
- Gastroenterology and Digestive Endoscopy Unit, Department of Surgery, Santa Chiara Hospital, Trento (Andrea Michielan, Elettra Merola, Filippo Vieceli, Teresa Marzia Rogger, Federica Crispino, Giovanni de Pretis, Nicolò de Pretis)
| | - Federica Crispino
- Gastroenterology and Digestive Endoscopy Unit, Department of Surgery, Santa Chiara Hospital, Trento (Andrea Michielan, Elettra Merola, Filippo Vieceli, Teresa Marzia Rogger, Federica Crispino, Giovanni de Pretis, Nicolò de Pretis)
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo (Federica Crispino)
| | - Chiara Sartori
- Surgical Pathology Unit, Department of Laboratory Medicine, Santa Chiara Hospital, Trento (Chiara Sartori, Nicola Libertà Decarli)
| | - Nicola Libertà Decarli
- Surgical Pathology Unit, Department of Laboratory Medicine, Santa Chiara Hospital, Trento (Chiara Sartori, Nicola Libertà Decarli)
- Pathology Unit, San Giovanni di Dio Hospital, Firenze (Nicola Libertà Decarli)
| | - Giovanni de Pretis
- Gastroenterology and Digestive Endoscopy Unit, Department of Surgery, Santa Chiara Hospital, Trento (Andrea Michielan, Elettra Merola, Filippo Vieceli, Teresa Marzia Rogger, Federica Crispino, Giovanni de Pretis, Nicolò de Pretis)
| | - Nicolò de Pretis
- Gastroenterology and Digestive Endoscopy Unit, Department of Surgery, Santa Chiara Hospital, Trento (Andrea Michielan, Elettra Merola, Filippo Vieceli, Teresa Marzia Rogger, Federica Crispino, Giovanni de Pretis, Nicolò de Pretis)
- Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona (Nicolò de Pretis), Italy
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Rogger TM, De Marchi G, Brozzi L, Amodio A, Orsolini G, de Pretis N, Conti Bellocchi MC, Crinò SF, Gabbrielli A, Ciccocioppo R, Frulloni L. Immunoglobulin G4-Related Disease Responder Index Correlates With the Risk of 1-Year Relapse in Type 1 Autoimmune Pancreatitis. Pancreas 2021; 50:879-881. [PMID: 34347736 DOI: 10.1097/mpa.0000000000001843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Type 1 autoimmune pancreatitis (AIP) is a manifestation of immunoglobulin G4-related diseases (IgG4-RD). To evaluate the activity of the disease, the IgG4-RD responder index (RI) has been created. This study evaluated the IgG4-RD RI as prognostic factor of 1-year disease relapse. METHODS Patients diagnosed with type 1 AIP between January 2012 and December 2016, with available magnetic resonance imaging and IgG4 dosage, were enrolled. Immunoglobulin G4-RD RI was calculated at baseline (time 0), and at 3 to 6 and 12 to 18 months after the end of steroid therapy (time 1 and time 2, respectively). RESULTS Thirty-three patients were included in the study. Immunoglobulin G4-RD RI was 8.9 (standard deviation [SD], 3.8) at time 0, 2.4 (SD, 3.1) at time 1 (P < 0.0001 vs time 0), and 4.2 (SD, 3.9) at time 2 (P = 0.02 vs time 1). Fourteen patients who relapsed within 1 year showed a higher mean value of IgG4-RD RI at time 0 (10.9; SD, 4.3) versus 19 who did not (7.4; SD, 2.6; P = 0.012). This difference was observed also at time 2 (6.8 vs 2.1; P = 0.002). CONCLUSIONS Immunoglobulin G4-RD RI correlates with type 1 AIP disease activity, and it predicts disease relapse within 1 year.
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Affiliation(s)
| | | | | | | | - Giovanni Orsolini
- Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy
| | | | | | | | | | | | - Luca Frulloni
- From the Gastroenterology B Unit, Pancreas Institute
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Rogger TM, Michielan A, Sferrazza S, Pravadelli C, Moser L, Agugiaro F, Vettori G, Seligmann S, Merola E, Maida M, Ciarleglio FA, Brolese A, de Pretis G. Gastrointestinal tract injuries after thermal ablative therapies for hepatocellular carcinoma: A case report and review of the literature. World J Gastroenterol 2020; 26:5375-5386. [PMID: 32994695 PMCID: PMC7504251 DOI: 10.3748/wjg.v26.i35.5375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/11/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Radiofrequency ablation (RFA) and microwave ablation (MWA) represent the standard of care for patients with early hepatocellular carcinoma (HCC) who are unfit for surgery. The incidence of reported adverse events is low, ranging from 2.4% to 13.1% for RFA and from 2.6% to 7.5% for MWA. Gastrointestinal tract (GIT) injury is even more infrequent (0.11%), but usually requires surgery with an unfavourable prognosis. Due to its low incidence and the retrospective nature of the studies, the literature reporting this feared complication is heterogeneous and in many cases lacks information on tumour characteristics, comorbidities and treatment approaches.
CASE SUMMARY A 77-year-old man who had undergone extended right hepatectomy for HCC was diagnosed with early disease recurrence with a small nodule compatible with HCC in the Sg4b segment of the liver with a subcapsular location. He was treated with percutaneous RFA and a few week later he was urgently admitted to the Surgery ward for abdominal pain and fever. A subcutaneous abscess was diagnosed and treated by percutaneous drainage. A fistulous tract was then documented by the passage of contrast material from the gastric antrum to the abdominal wall. The oesophagogastroduodenoscopy confirmed a circular wall defect at the lesser curvature of gastric antrum, leading directly to the purulent abdominal collection. An over-the-scope clip (OTSC) was used to successfully close the defect
CONCLUSION This is the first reported case of RFA-related GIT injury to have been successfully treated with an OTSC, which highlights the role of this endoscopic treatment for the management of this complication.
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Affiliation(s)
- Teresa Marzia Rogger
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Andrea Michielan
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Sandro Sferrazza
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Cecilia Pravadelli
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Luisa Moser
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Flora Agugiaro
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Giovanni Vettori
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Sonia Seligmann
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Elettra Merola
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S.Elia-Raimondi Hospital, Caltanissetta, Caltanissetta 93100, Italy
| | | | - Alberto Brolese
- Department of Surgery, Hepato-biliary Surgery Unit, Santa Chiara Hospital, Trento 38122, Italy
| | - Giovanni de Pretis
- Department of Surgery, Gastroenterology and Digestive Endoscopy Unit, Santa Chiara Hospital, Trento 38122, Italy
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