Summary
Background
One‐third of Crohn's disease (CD) patients will undergo abdominal surgery within the first 5 years of diagnosis.
Aim
To review the available evidence on pre‐operative optimisation ...of CD patients.
Methods
The literature regarding psychological support, radiological imaging, abdominal abscess management, nutritional support, thromboembolic prophylaxis and immunosuppression in the perioperative setting was reviewed.
Results
For diagnosis of fistulas, abscesses and stenosis, ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) have a high diagnostic accuracy. Under either CT or US guidance, it is possible to perform abscess percutaneous drainage (PD), which, with systemic antibiotic therapy, should be the first‐line approach to intra‐abdominal abscesses. CD patients with weight loss <10% within the last 3–6 months, body mass index < 18.5 kg/m2 and/or albumin levels <30 g/L, are at an increased risk of post‐operative complications. Pre‐operative nutritional support should be used in these patients. IBD patients undergoing surgery have a higher risk of venous thromboembolic disease than patients with colorectal cancer, and current guidelines recommend that they should receive prophylaxis with heparin. Whether the use of anti‐TNF agents before surgery increases the likelihood of post‐operative complications, is the subject of much debate. To date, cumulative evidence from most studies (all retrospective) suggests that there is no such risk increment. Prospective studies are necessary to firmly establish this conclusion.
Conclusions
Preparation for surgery requires close interaction between surgeons, gastroenterologist, radiologists, psychologists and the patient. Correct pre‐operative planning of surgical treatment has a major impact on the outcome of such treatment.
Linked Content
This article is linked to Goncalves et al papers. To view these articles visit https://doi.org/10.1111/apt.14808 and https://doi.org/10.1111/apt.14860.
Abstract
Background
Endoscopic remission is associated with better outcomes in ulcerative colitis (UC). However, colonoscopy (CS) is invasive and poorly tolerated by patients. Recently, we developed ...and externally validated non-invasive ultrasonography based criteria Milan ultrasound criteria (MUC) to assess and grade endoscopic activity in UC. We also confirmed that a MUC score > 6.2 is a valid cut-off to discriminate endoscopic activity, defined by a Mayo endoscopic subscore > 2.
Aim of this study was to assess the predictive role of MUC on disease course in a prospective cohort of UC patients.
Methods
UC consecutive patients were followed for at least 12 months after performing baseline bowel US. UC-related outcomes, including need of treatment escalation (defined as the need of corticosteroids or change/optimization of immunosuppressants), hospitalization and surgery, were assessed at 1 year by logistic regression analysis, and were analyzed after long term follow-up (5 years) using Kaplan-Meier survival analysis.
Fig. 1A and 1B. Kaplan–Meier curves for the cumulative probability of hospitalization and surgery in patients with Milan ultrasound criteria (MUC) < 6.2 (solid line) or MUC > 6.2 (dotted line). (p= 0.046; p= 0.023; respectively).
Fig. 1C and 1D. Kaplan–Meier curves for the cumulative probability of hospitalization and surgery in patients with Mayo endoscopic subscore 0–1 (solid line) or 2–3 (dotted line). (p= 0.035; p= 0.071; respectively).
Results
87 UC consecutive patients were included in the study, 31 (36%) were in endoscopic remission (Mayo endoscopic subscore 0–1) and 56 (64%) in endoscopic activity (Mayo endoscopic subscore 2–3). MUC and Mayo endoscopic subscore significantly correlated at baseline (Spearman’s rank correlations rho= 0.642; 95% confidence interval (CI) 0.499 to 0.751; p < 0.001). The multivariable analysis identified as independent predictors of need of treatment escalation throughout the 12-month period as being: MUC > 6.2 (OR: 5.95, 95% CI: 1.32–26.76, p < 0.020) and a partial Mayo score (PMS) > 2 (OR: 26.88, 95% CI: 5.01–144.07, p < 0.001). Kaplan-Meier survival analysis of long-term follow up demonstrated a lower cumulative probability of need for surgery and hospitalization in patients with MUC < 6.2 compared to MUC > 6.2 (Fig. 1A and 1B), as well as in patients with a Mayo endoscopic subscore of < 1 compared to Mayo endoscopic subscore of 2–3 (Fig. 1C and 1D).
Conclusion
MUC is a novel non invasive tool that predicts the course of UC in the short and long term follow-up.
Background: Hypercholesterolaemia often occurs in primary biliary cirrhosis (PBC) as a result of chronic cholestasis, but whether these patients are exposed to greater cardiovascular risk is unknown. ...Aim: To establish whether hypercholesterolaemia is associated with subclinical atherosclerosis in PBC. Patients: 103 consecutive patients with PBC (37 with total cholesterol ⩾6.21 mmol/l) and 37 controls with hypercholesterolaemia, and 141 matched controls with normocholesterolaemia. Methods: Ultrasound imaging of carotid artery to determine intima–media thickness (IMT) and stenosis. Results: Controls with hypercholesterolaemia had higher IMT and prevalence of carotid stenosis compared with patients with hypercholesterolaemic PBC (mean (SD) 0.850 (0.292) mm v 0.616 (0.137) mm, pc<0.001; 43% v 19%, pc = 0.129) who, in turn, were similar to the 66 patients with normocholesterolaemic PBC (0.600 (0.136) mm; 5%). Compared with subjects with normocholesterolaemia, controls with hypercholesterolaemia, but not patients with hypercholesterolaemic PBC, had an increased risk of raised IMT (odds ratio (OR) 5.4, 95% confidence interval (CI) 2.5 to 11.9, p<0.001; and 0.7, 0.3 to 2.0, p = 0.543) or carotid stenosis (8.2, 3.4 to 20, p<0.001; and 2.5, 0.9 to 6.9, p = 0.075). In PBC, compared with younger patients without hypertension, the risk of increased IMT was OR (CI) 3.1 (0.6 to 17; p = 0.192) in patients with hypertension or old age, but not hypercholesterolaemia, and 4.6 (0.8 to 27; p = 0.096) in patients who also had hypercholesterolaemia. The corresponding figures for risk of stenosis were 3.6 (0.4 to 36; p = 0.277) and 15.8 (1.8 to 141; p = 0.014). Conclusions: Hypercholesterolaemia is not consistently associated with subclinical atherosclerosis in PBC, but should be treated if other risk factors for cardiovascular disease are also present. The search for factors that may protect patients with hypercholesterolaemic PBC against atherosclerosis should be encouraged.
High antigenic compatibility and low toxicity is associated with xenograft transplantation of porcine tissues in immunodeficient human recipients. We hypothesized that adeno-associated viruses (AAVs) ...of porcine origin could be highly compatible to human tissues and thus of good efficiency and low toxicity for in vivo gene transfer. Porcine tissues were screened by PCR for the presence of AAV using primers designed to bind conserved regions and amplify variable regions of an alignment of several AAV sequences available on GenBank. We isolated new AAV capsid sequences from porcine tissues and successfully generated a recombinant AAV2/po1 vector by transfection. The AAV2/po1 vector was not cross-neutralized by antisera generated against all other commonly used AAVs (serotype 1, 2, 3, 4, 5, 7 and 8) indicating a distinct antigenic profile. Preexisting immunity to AAVpo1 could not be detected in the human sera evaluated. In mice, AAV2/po1 particles expressing beta-galactosidase or green fluorescent protein demonstrated high transduction efficiency in muscle fibers and the retina after intramuscular or intraocular administration. Biodistribution experiments following systemic administration showed efficient gene transfer exclusively in muscle fibers. Novel AAVs derived from porcine tissues may contribute to the generation of new preventive or curative clinical modalities acceptable for human use.
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