The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn’s ...disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn’s disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
Purpose
Over 50% of patients suffering from Crohn’s disease (CD) require surgery in their lifetime. Predictors/risk factors of post-operative morbidity and mortality in CD are poorly investigated. We ...aimed to assess the risk factors of post-operative morbidity/mortality in CD.
Methods
We performed a retrospective cohort study in which all CD patients operated and followed up at our tertiary Inflammatory Bowel Disease Centre from 2014 to 2019 were enrolled. For each patient, we evaluated patient-dependent, disease-dependent and surgery-dependent variables. All patients underwent small bowel and/or colic resections.
Results
Of the 165 operated patients, forty-two (25.5%) developed post-operative complications (major complication rate = 9.8%) including wound infection (12.1%), respiratory complications (4.8%), prolonged ileum (4.2%), anastomotic leak (3.6%), urinary infections (3%), abdominal abscess (2.4%), anastomotic bleeding (3.6%), abdominal bleeding (1.2%) and obstruction (0.6%). Two subjects (1.2%) required re-operation within 30 days, and one died. A surgery duration < 141 min was predictive of a better post-operative outcome (sensitivity 80.9%, specificity 43.1%, PPV 32.7%, NPV 86.9%). The multivariable analysis showed stricturing/fistulizing behaviour (OR 3.7, 95% CI 1.6–6.4,
p
= 0.02), need for total parenteral nutrition (OR 4.1, 95% CI 2.4–9.2,
p
= 0.01), pre-operative bowel cleansing (OR 0.6, 95% CI 0.41–0.83,
p
= 0.01) and surgery duration < 141 min (OR 0.2, 95% CI 0.08–0.7,
p
= 0.03) as the only risk factors associated with post-operative morbidities.
Conclusions
About 25% of CD patients develop post-operative complications. Several patient-related, disease-related and surgery-related factors should be considered risk factors for post-operative morbidity. The recognition of these factors, as well as a multidisciplinary approach to the pre-operative management of CD, could reduce post-operative complications.
Background
Complete mesocolic excision with central vascular ligation (CME) produces an optimal colonic cancer specimen. The ability of expert laparoscopic surgeons to produce equivalent specimens is ...unknown.
Methods
Fresh specimen photographs and clinicopathological data from patients undergoing laparoscopically assisted CME at St Mark's Hospital, Harrow, were submitted for independent pathological review. Surgery was performed by a mixture of consultant specialists and trainees under consultant specialist supervision, between February 2010 and July 2011. The planes of surgery were graded and tissue morphometry was performed using standard methods. The results were compared with published data from open CME and non‐CME surgery.
Results
In total, 69 patients were identified, and in 96 per cent resection was performed completely or partially by surgical trainees. Laparoscopic CME produced a similar specimen to open CME. The laparoscopic mesocolic plane resection rate was similar to that for open surgery (90 versus 88 per cent). The distance between the bowel wall and site of vascular division was similar for laparoscopic and open right‐sided CME (92 versus 95 mm respectively). The corresponding values for left‐sided CME were also similar (103 versus 107 mm). Compared with values from two non‐CME series, laparoscopic CME had a higher mesocolic plane rate (90 versus 40 and 48 per cent), and resected more tissue between the bowel wall and the vascular division (right‐sided: 92 versus 72 and 76 mm; left‐sided: 103 versus 85 and 70 mm). The lymph node yield remained low following laparoscopic CME compared with open CME (median 18 versus 32; P < 0·001) and identical to that of non‐CME surgery (median 18).
Conclusion
Laparoscopic CME can be performed to the same standard as open surgery by supervised trainees. However, this did not increase the lymph node yield.
Feasible but nodal counts not up
Intussusception is a common condition of bowel obstruction in pediatric patients. However, 5% of all cases occur in adults, mostly aged over fifty, with no difference based on sex, representing about ...1% of all causes of bowel obstruction. Compared to pediatric population, it is triggered by a pathologic lead point in about 85% of cases, represented in 60% of cases by malignant and benign neoplasms. Among these neoplasms, an inflammatory fibroid polyp (IFP), a benign neoplastic submucosal lesion also known as Vanek's tumor, is considered a very uncommon cause of adult intussusception. Clinical presentation could differ by location and size of tumor, and may include abdominal pain, nausea, vomiting, diarrhea or constipation, bleeding, weight loss, palpable abdominal mass, bowel obstruction, and gastrointestinal bleeding. Considering its common and non-specific symptoms, radiologic imaging plays a key role in the diagnosis of an IFP, especially computed tomography (CT) scan, which represents the most sensitive modality to confirm intussusception. However, bowel sonography (BS) has become an accurate procedure in various pathological intestinal diseases, also including intussusception. In this paper, we report a rare case of ileo-ileal intussusception secondary to Vanek's tumor diagnosed by BS.
Objectives: The goals of this study were to assess the air quality in subway systems in the northeastern United States and estimate the health risks for transit workers and commuters. Methods: We ...report real-time and gravimetric PM2.5 concentrations and particle composition from area samples collected in the subways of Philadelphia, Pennsylvania; Boston, Massachusetts; New York City, New York/New Jersey (NYC/NJ); and Washington, District of Columbia. A total of 71 stations across 12 transit lines were monitored during morning and evening rush hours. Results: We observed variable and high PM2.5 concentrations for on-train and on-platform measurements during morning (from 0600 hours to 1000 hours) and evening (from 1500 hours to 1900 hours) rush hour across cities. Mean real-time PM2.5 concentrations in underground stations were 779±249 , 548±207 , 341±147 , 327±136 , and 112±46.7 μg/m3 for the PATH-NYC/NJ; MTA-NYC; Washington, DC; Boston; and Philadelphia transit systems, respectively. In contrast, the mean real-time ambient PM2.5 concentration taken above ground outside the subway stations of PATH-NYC/NJ; MTA-NYC; Washington, DC; Boston; and Philadelphia were 20.8±9.3 , 24.1±9.3 , 12.01±7.8 , 10.0±2.7 , and 12.6±12.6 μg/m3 , respectively. Stations serviced by the PATH-NYC/NJ system had the highest mean gravimetric PM2.5 concentration, 1,020 μg/m3 , ever reported for a subway system, including two 1-h gravimetric PM2.5 values of approximately 1,700 μg/m3 during rush hour at one PATH-NYC/NJ subway station. Iron and total carbon accounted for approximately 80% of the PM2.5 mass in a targeted subset of systems and stations. Discussion: Our results document that there is an elevation in the PM2.5 concentrations across subway systems in the major urban centers of Northeastern United States during rush hours. Concentrations in some subway stations suggest that transit workers and commuters may be at increased risk according to U.S. federal environmental and occupational guidelines, depending on duration of exposure. This concern is highest for the PM2.5 concentrations encountered in the PATH-NYC/NJ transit system. Further research is urgently needed to identify the sources of PM2.5 and factors that contribute to high levels in individual stations and lines and to assess their potential health impacts on workers and/or commuters.
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•A “river-tunnel” effect explains some of the variability in NYC subway station PM2.5 concentrations.•Stations next to river-tunnels have higher PM2.5 concentrations than those 2 or 3 ...stops away. These results were not observed between stations on a line which crosses the river over a bridge.•Other potential factors such as station age, depth, or size could not explain the variability as well.
It is well-documented that subway stations exhibit high fine particulate matter (PM2.5) concentrations. Little is known about the potential of river-tunnels to increase PM2.5 concentrations in subways. We hypothesized a “river-tunnel” effect exists: Stations adjacent to poorly ventilated tunnels that travel beneath rivers exhibit higher PM2.5 concentrations than more distant stations. Accordingly, the PM2.5 concentrations were monitored at stations adjacent to and two- and three-stations distant from the river-tunnel. Multivariate linear regression analysis was conducted to disentangle how proximity to a river-tunnel and other factors (e.g., depth) influence concentrations. Stations adjacent to a river-tunnel had 80–130% higher PM2.5 concentrations than more distant stations. Moreover, distance from a river-tunnel was the strongest PM2.5-influencing factor This distance effect was not observed at underground stations adjacent to a river-bridge. The “river-tunnel” effect explains some of the inter-station variability in subway PM2.5 concentrations. These results support the need for improving ventilation systems in subways.
Abstract Introduction The breast and salivary gland tissue share embryologic and thus pathological similarities. Acinic cell carcinoma (ACC) is a typical tumor in salivary glands, but rarely arises ...in breast too. We reviewed 38 cases of mammary ACC reported in literature and our case, the first ACC born within a fibroadenoma. Materials and methods Data were collected by a research for the key words acinic cell carcinoma breast on Pubmed in March 2014, including a case treated in our department. All reviewed cases were compared for clinical approach and histological pattern. Results To date 23 articles presenting cases of ACC of the breast are reported in literature. We included in our review 38 cases previously described and one new case. The histological pattern was predominantly solid with a microglandular structure. All the tumor cells were cytologically characterized by monotonous round cells with a finely granular, weakly eosinophilic, or clearly vacuolated cytoplasm. The most of the cells were intensely stained with anti-lysozime, anti-amylase, anti-α1-chimotripsin, anti-EMA and anti-S100 protein antisera. Immunohistochemistry was also performed to point out: estrogen receptor (ER), progesterone receptor (PR), androgen receptors (AR), human epidermal growth factor receptor 2 overexpression (HER2/neu), E-cadherin (E-cad), cytokeratin-7 (CK7), gross cystic disease fluid protein 15 (GCDFP15), smooth muscle actin (SMA). Conclusion ACC of the breast is a rare tumor, showing similarities with the salivary gland counterpart, above all in terms of good prognosis, and differences from the ordinary invasive breast carcinoma. Further investigations are needed to elucidate the true histogenesis and the correct treatment.
Aim
Tumour neoangiogenesis is a key factor in tumour progression and metastatic spread and the possibility to assess tumour angiogenesis might provide prognostic information. The aim of this study ...was to establish the role of probe‐based confocal laser endomicroscopy (p‐CLE) in the identification of vascular architecture and specific morphological patterns in normal colorectal mucosa and malignant lesions during routine endoscopy.
Method
Fourteen consecutive patients with colorectal cancer were included. The following features were identified and then compared between normal and neoplastic mucosa on p‐CLE images: vessel shape (straight vs irregular) vessel diameter the ‘branching patterns’ vessel permeability (fluorescein leakage) and blood flow (normal vs defective flux). Immunohistochemistry was used to confirm the presence and to study the morphology of vascular structures (CD‐34 staining) and ‘neo‐vessels’ (WT‐1 staining) on tumour and normal mucosal sections.
Results
Tumour vessels appeared as irregular, ectatic and with a highly variable calibre and branching patterns on p‐CLE images. The mean diameter of tumour vessels was significantly larger than those in normal mucosa (weighted mean difference 3.38, 95% CI 2.65–4.11, P = 0.01). Similarly, ‘vessel branching’ (OR 2.74, 95% CI 1.23–6.14, P = 0.01), fluorescent dye ‘extravasation’ (OR 3.46, 95% CI 1.39–8.57, P = 0.01) were significantly more frequent in colorectal cancer than in normal colorectal mucosa. Immunohistochemistry corroborated the p‐CLE findings, showing higher vascularity in tumour sections due to neoformed vessels, presenting irregular patterns.
Conclusion
Probe‐based confocal laser endomicroscopy provides a noninvasive characterization of the microvascular architecture of colonic mucosa. Different morphological patterns have been described, discriminating normal and malignant microvascular networks in colorectal mucosa.
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