Surveillance for Dysplasia and Cancer

The clinical heterogeneity of IBD is reflected in the heterogeneity in the macro and microscopic feature and makes cancer surveillance in this population much more challenging than in the general population. IBD associated risk factors for colorectal cancer are well known and this is the reason why any patient with a history of extensive disease, whether UC or CD, of more than 10 years must undergo a complete colonoscopy with multiple biopsies every 2 years. Any dubious situation should be...

Surgical Prevention of Colorectal Cancer in FAP

Familial adenomatous polyposis coli (FAP) may not be considered a single disease entity with standardised guidelines for operative treatment. However, prophylactic colectomy after the manifestation of polyps but prior to the development of colorectal cancer remains the most effective prevention of col-orectal cancer in FAP. The optimal timing of prophylactic surgery remains a clinical decision taken independently of mutation analysis. In the case of the classic FAP phenotype, restorative...

Effect of IBD on Pregnancy

As for the progress of pregnancy during IBD, many studies show that pregnant patients may have an ordinary gestational course during the stages of disease quiescence even if there still is, for reasons not yet explained, a risk that is about twice as high compared with healthy women to have complications such as delay of foetal intrauterine growth, prematurity and low birth weight. Therefore, strict obstetrical follow-up, particularly during the third trimester, is necessary 14,15 . There is...

Discussion

This systematic review has highlighted some very important differences in outcome between restorative proctocolectomy and IRA for the patient with FAP. The results on functional outcome suggest a favourable outcome towards the IRA procedure with regards to stool frequency over a 24-h period, need for defecation at night, incontinence (both over a 24-h period and at night) and pad usage. These finding are perhaps expected in a patient with a retained, functioning rectum. Interestingly, IPAA was...

Rectal Cancer Risk

IRA carries a definite cancer risk in FAP due to the remaining rectal stump 3,4 , with a long-term rectal cancer risk reported to increase from 4 at 5 years to 25 at 20 years post-operatively 5 . More recently it has been suggested that absolute patient age is the determinant factor for cancer development rather than the length of post-operative follow-up 6 . This has led some to suggest that IRA should be converted to IPAA before the age of 50 7 . Several factors are thought to increase the...

Introduction

Patients with inflammatory bowel disease (IBD) are at an increased risk for colorectal cancer (CRC) 1-4 , but the quantisation of the risk of CRC in this specific population varies widely in different studies. However, CRC complicating ulcerative colitis (UC) and Crohn's disease (CD) only accounts for 1-2 of all cases of CRC in the general population. Most cases of CRC are either sporadic (65-85 ) or familial (10-30 Fig. 1) 3-4 . CRC is considered a serious complication of the disease and...

Ankylosing Spondylitis

This chronic inflammatory disease is characterised by a progressive ligament calcification with hardening of the spine that reduces the function of the spine and therefore causes disability 13 . Although at present there are few clinical trials to confirm the benefits of therapeutic exercise in treating ankylosing spondylitis 14 , it is firmly believed that a rehabilitative program for patients with IBD should include 2. Achieving and maintaining correct posture. 3. Maintaining correct...

Surveillance Guidelines

Guidelines have recently been published by authors from different expert centres 16-19 . Since duration and anatomic extent of the ulcerative colitis have been shown to be the two strong and independent risk factors regarding the development of cancer, special attention to these variables is crucial in the practice of surveillance. The UK guidelines for surveillance in ulcerative colitis 19 state that surveillance colonoscopy should preferably be performed in disease remission, it should be...

Upper Gastrointestinal Polyps and Cancer

After the colon and rectum, the duodenum is the second most commonly affected site of polyp development in FAP 2,3 . Duodenal adenomas can be found in 30-70 of patients 2-4 and the lifetime risk of Table 1. Extra-colonic manifestations of familial polyposis Stomach fundic gland polyps, adenomatous polyps, cancer Duodenum and small bowel duodenal adenomas, periampullary cancer, small-bowel adenomas, cancer, lymphoid polyps of ileum Gallbladder, bile duct, pancreas adenomas, cancer Desmoid tumors...

Perianal and Colonic Crohns Disease

When isolated perianal Crohn's disease is present, loop ileostomy is often offered to patients as a temporary or definitive solution. Laparoscopic ileostomy construction is easily performed 20 and at the same time it gives the possibility of performing a complete abdominal exploration in order to detect additional sites of disease. Bowel obstruction due to bowel twisting is a possible complication and therefore particular care has to be taken to mark the bowel in order to exteriorise it in the...

Depression How Crohns Disease Patients Defend Themselves

Depression itself is a mechanism of defence in a person whose quality of life is severely affected by Crohn's colitis. The more the patient interacts with people, deals with his her job, enjoys - or tries to enjoy - social life, the more he she gets frustrated and suffers, as routine daily activities are prevented by anal soiling, frequent diarrhoea or abdominal pain Therefore, depression, i.e. refusal to participate actively in life, introversion and self-confinement to a comfortable jail...

Elective Procedures in Crohns Disease of the Colon

Throughout their lifespan, 70-80 of patients suffering form CD require surgical intervention. In 10-15 years from the first surgery, approximately 40-50 of patients require the next operation due to recurrence 20, 21 . Elective surgical strategy for Crohn's disease of the colon is somehow different from the strategy for CD of the small intestine. Due to the role of the small intestine, surgical procedures must aim to minimise the risk of short bowel syndrome. The large bowel is mainly...

Other Agents under Trial

Other agents under investigation in colorectal chemoprevention include difluoromethylornithine (DFMO), which irreversibly inhibits ornithine decarboxylase and blocks cell proliferation. Ursodeoxy-cholic acid reduces the concentration of the secondary bile acid deoxycholic acid in the colon and affects arachidonic acid metabolism 9-11 . 3-hydroxy-3-methylglutaryl Coenzyme A reductase inhibitors are usually used in the setting of lowering cholesterol but also have antioxidant anti-inflammatory...

Cowden Disease

Cowden disease is an uncommon autosomal dominant disorder and is the family name of the original report patient, Rachel Cowden. This syndrome is a rare disorder that is inherited in autosomal dominant manner with intrafamilial and interfamilial differences in symptom expression. In Cowden disease, one sees facial trichilemmomas, acral keratosis and oral mucosal papillomas. This disorder is also associated with breast and thyroid cancer. There are numerous colic and small-intestinal polyps. They...

Emergent Issues and Trends in Research

The ideal gold standard would be a gene technique that would allow the removal of the diseased gene and implant a disease-free gene. At present this is still pure speculation. Most of the research deals with systems for screening the germline mutations in the adenoma-tous polyposis coli (APC) gene that predisposes the disease susceptibility in familial adenomatous polyposis. Nowadays, there are technical systems that detect the mutations in APC gene. They might be useful in the molecular...

Dietary Restriction Social and Sexual Dysfunction

The studies reporting on dietary restriction, social restriction, and sexual dysfunction are shown in Table 4. The results from meta-analysis of these outcomes are shown in the Forrest plot in Figs. 3 and 4. The incidence of social restrictions following 58 IPAA and 85 IRA procedures (33, 35), was found to be significantly lower at 3.5 following IRA as compared to 13.8 following IPAA (OR 6.04, CI 1.53-23.78). There was no significant difference between IPAA and IRA in terms of need for dietary...

Nutritional Care in Children with Crohns Disease

Between 15 to 40 of children with Crohn's disease suffer from malnutrition and growth failure, puberty retardation and development of secondary sexual characteristics retardation 4 . The slowing down of height velocity has been also observed 4, 5 . What is clinically relevant is that malnutrition may affect as many as 25 of children even before the apparent onset of the disease 5 . Some factors are involved such as the catabolic state during the acute and or persistent active phase, anorexia...

References

Frield W, Caspari R, Sengteller M et al (2001) Can APC mutation analysis contribute to therapeutic decision in familial adenomatous polyposis Experience from 2. Contessini-Avesani E, Botti F, Negri C et al (2004) Familial adenomatous polyposis. Surgical treatment when and how. Tech Coloproctol 8 S309-S314 3. Moisio AL, Jarvinen H, Peltomaki P (2002) Genetic and clinic characterization of familial adenomatous polyposis a population based study. Gut 50 845-850 4. Crabtree D, Tomlinson IPM,...

Nephrotoxicity from Medical Treatment

Renal toxicity is unusual with the drugs commonly utilised to treat IBD 91-95 , buthappens more frequently during treatment with cyclosporine, with reported incidence of up to 19 96-98 . However, the risk of irreversible damage is very low if cyclosporine dosage does not exceed 5 mg kg day and if the creatinine level does not increase over 30 of the normal level 99 . Results from a review showed that a > 30 increase in serum creatinine was present in 6 of patients treated with oral or...

Cancer Screening and Colonoscopy Surveillance

In the past, the indication for prophylactic colectomy for patients with longstanding ulcerative colitis was mainly based on the disease history and the clinical risk factors mentioned above. Today, with the availability of colonoscopy and the recognition of the dys-plasia-precancer-cancer sequence, surveillance colonoscopy with serial colonoscopic examinations and mucosal biopsies is thought to allow for a more adequate individual assessment of the cancer risk and firm recommendation for...

Screening and Treatment Options of Patients with Dysplasia Associated IBD

The evidence of the association of dysplasia with cancer in patients with IBD has been noticed since the first publication of Crohn and Rosenberg early in the 1900s 41-43 . The fact that dysplasia is commonly seen near areas of invasive carcinoma in up to 74 of resection specimens from IBD patients, has lead to the conclusion that this is a precursor to the invasive lesion 44 . The diagnosis of dysplasia in patients with IBD is a crucial step because in some centres it will leave the patient...

Capsule Endoscopy in Crohns Disease

Video capsule endoscopy (VCE) is a new, noninva-sive imaging technique for the complete small bowel. The video capsule is a small device with a diameter of 11 mm and a length of 26 mm, which can be swallowed. It contains six light-emitting diodes, a lens, a colour camera chip and two batteries. The video capsule obtains two images per second. Video images are transmitted by means of radiotelemetry to the sensor array attached to the body with a belt. Images from a period of time as long as 8 h...

Cytotoxic Chemotherapy

Systemic chemotherapy has been administered to patients with DTs continually growing despite treatment with NSAIDs or anti-oestrogens or rapidly increasing in size thus leading to life-threatening complications. However, chemotherapy is rarely employed because of its toxicity. The published reports regard single cases or small numbers of patients. All treated patients were affected with large tumours, had severe symptoms or major complications. The DTs continued to grow even if medically...

Uric Acid Stones

Crohn Disease Skin

Generally, uric acid renal stones are likely to form in the following circumstances (1) increased excretion Fig. 1. Bilaterally dilated renal calices, renal and ureteral calculi (white arrows) and calcifications (black arrow) in a patient with longstanding CD Fig. 1. Bilaterally dilated renal calices, renal and ureteral calculi (white arrows) and calcifications (black arrow) in a patient with longstanding CD of uric acid in the urine, (2) persistently concentrated urine, (3) persistently low...

Surveillance and its Limitations

Mucosal dysplasia documented by surveillance colonoscopy used clinically to identify the high risk patients has proven to have significant limitations. Sampling error, presence of acute mucosal inflammation, differences in pathological interpretation (observer variations) and variable patient compliance are factors that might interfere with the diagnostic accuracy. The reliability of dysplasia as a precursor of cancer is poor 22 . The histological interpretation is often subjective and of...

Clinical Studies on Artificial Nutrition in Crohns Disease

Artificial nutrition (enteral and parenteral) represents a widespread approach to many gastrointestinal disorders such as intestinal failure and chronic intestinal pseudo-obstruction, inflammatory bowel disease (IBD), severe exocrine pancreatic insufficiency due to cystic fibrosis, enteric and pancreatic fistulas, swallowing disorders, and other conditions secondary to other severe gastrointestinal disease or major digestive surgery leading to malnutrition. The availability of different enteral...

Crohns Disease

There are very few studies on quality of life issues in Crohn's disease. The issues that impact principally on quality of life are as follows 1. The fear of recurrent Crohn's disease. 2. The fear of ill health and compromised work prospects. 3. Perianal disease often with psychosexual complications. 4. Impact of bodily image from multiple scars and anorectal sepsis and stomas. 5. Sexual morbidity and infertility. In Crohn's disease there are often long periods of quiescence between successful...

Pathophysiology

Healing is a complex process not yet completely understood. Soon after tissue damage, the inflammation phase takes place with subsequent migration and proliferation of macrophages, lymphocytes and fibroblasts thereafter, neoangiogenesis and fibro-plasias lead to wound closure, and finally, contraction of the scar tissue and remodelling complete the healing process. This organised sequence of events can be retarded by many endogenous factors such as ischaemia or poor blood supply, and...

Hepatobiliary Complications

Complications Crohn Disease

The incidence of hepatobiliary complications ranges from 5 to 15 in IBD patients. These complications include steatosis, cholelithiasis and PSC. An Italian study reported an overall prevalence of hepatobiliary alterations, e.g. steatosis and altered liver function test results, in 12 of IBD patients. A recent study by Bargiggia et al. reported gallstones, liver steatosis and liver enlargement in about 55 of 511 IBD patients undergoing abdominal ultrasound Fig. 3 . Cholelithiasis is reportedly...

Anti Inflammatory Medications

Several studies demonstrated that sulphasalazine and mesalazine are efficacious at high dose 3 g or more for CD, but there is no evidence that these drugs are effective in fistula healing. Also corticosteroids have no proven efficacy in the treatment of fistulizing Crohn's disease. In most of the studies on steroid efficacy, patients were not randomized for fistulae 9 . A recent review 10 has associated in patients with fistulizing CD, the use of corticos-teroids with deleterious outcome,...

Intestinal Strictures are a Commonly Encountered Problem in Patients with Crohns Disease

Intestinal strictures are a commonly encountered problem in patients with Crohn's disease, resulting in bowel obstruction and eventually in repeated bowel resection and short bowel disease. Over one third of patients with Crohn's disease have a clear stenosing disease phenotype, often in the absence of luminal inflammatory symptoms 39 . At the foundation, as in other organs and tissues, there is transformation and activation of fibroblasts and smooth muscle cells that underlie fibrogenesis in...

Mesenteric Fibromatosis

Mesenteric Fibromatosis

The term desmoid was first used by Muller 1 to describe the tendon-like aspect and the hard consistency of this type of proliferation desmos in Greek means band . Desmoid tumours DTs are classified as extra- or intra-abdominal. The extra-abdominal DTs arise from fascial or musculoaponeurotic structures predominantly of the abdominal wall Fig. 1a, b, c and occasionally of the shoulder girdle, chest wall, inguinal region and extremities. They present as a firm, smooth, painless, progressively...

Endosonographic Anatomy of the Anal Canal

Normal External Rectum

Knowledge of the anal canal and pelvic floor anatomy is required in order to better understand how Fig. 8. Normal ultrasonographic six-layer structure of the mid anal canal in a male. Axial image a , schematic representation b perianal sepsis develops and to more accurately classify fistulae and abscesses. On ultrasound, six hypoe-choic and hyperechoic layers can be seen in the normal anal canal 14 . The ultrasonographer must have a clear understanding of what each of these six lines represent...

Surgical Indications in Crohns Disease and Preoperative Preparation

Table 1 summarises indications for surgical treatment in Crohn's disease 4, 12, 13 . Surgery may be either scheduled or urgent. The subdivision into absolute and relative indications is partly arbitrary. Regardless of CD, intestinal perforation is considered to require urgent surgical treatment, but determining Table 1. Indication for surgical therapy Intestinal obstruction especially terminal ileum Intestinal perforation Complication of the disease process Intestinal bleeding Recalcitrant...

Calcium Oxalate Stones

Calcium oxalate is the most common type of kidney calculi not only in IBD patients but also in the general population. However, in the latter, urinary oxalate concentration is often normal and the formation of stones is mainly secondary to the abnormalities in its solubility. In contrast, the pathogenesis in IBD patients appears to be related to hyperoxaluria combined with fluid depletion. It has been shown that hyperox-aluria is present in two thirds of patients with ileal disease, or those...

Recurrence of Crohns Disease

Crohn's disease is considered to be an autoimmune disorder. Therefore, the possibility of recurrence within the graft is an important issue. So far, only two well-documented cases of recurrent disease have been reported. The first case was a 33-year-old female, who underwent small-bowel transplantation in December 1994. After induction with donor bone marrow infusion and with OKT3, immunosuppres-sion consisted of tacrolimus and methylpred-nisolone. Only 7 months post-transplant did the Fig. 4....

Risk of Cancer and Endoscopic Surveillance

Segmental Colectomy

The first description of a cancer of the colon complicating regional enteritis was described in 1948 79 . After this, published works abounded with reports of colorectal cancer in series of patients with Crohn's disease 80 . In a recent population-based study 81 , Bernstein et al. determined the incidence of cancer by linking records from the IBD and non-IBD cohort with the Comprehensive Cancer Care Manitoba Registry. IBD patients were matched 1 10 to randomly selected members of the population...

Irritable Pouch Syndrome IPS

IPS is a functional disorder diagnosed in symptomatic patients who suffer mainly from increased bowel frequency, urgency and abdominal pain without endoscopic or histologic evidence of rectal cuff or pouch inflammation 75 . Clinical features overlap with those of pouchitis and resemble those of irritable bowel syndrome. The aetiology is unclear, and is probably multifactorial in nature. Brain-gut factors may play a role in the pathophysiology of IPS. It is currently a diagnosis of exclusion. A...

Abscess

Ischiorectal Abscess

Infection may spread and seek the path of least resistance Fig. 1 . It may extend downwards into the intersphincteric space resulting in a perianal abscess A , upwards inside the longitudinal muscle layer within the gut wall causing an intermuscular abscess, or upwards outside the gut wall resulting in a supral-evator abscess E . It may spread across the external sphincter B at any level resulting in an ischiorectal abscess which may also extend upwards or downwards C . Furthermore,...

Hand Assisted Technique with Personal Adjustments

Kock Pouch

When we began using HAL, the type of hand-port we chose was a Lap-Disc Ethicon Endosurgery, USA Fig. 4 . This system is made of rubber rings and a double circle which allows its rotation and closure as a diaphragm around the hand, while at the bottom, the rubber ring models its form, which is generally opened in the hypogastrium site, on the abdominal wall 7-cm incision according to Pfannenstiel . The patient is adjusted as for a cholecystectomy with parted legs and the operator in between, and...

Sexual Dysfunction Secondary to Surgical Treatment

Sexual dysfunction following rectal surgery for IBD has been reported in 1-27 of cases but dysfunction is often partial and transient 119, 128, 132, 133, 142-148 . This is usually due to damage of neurological structures during pelvic dissection, although psychogenic or vasculogenic factors may contribute 149 . Normal sexual function in males is under the control of both the sympathetic and parasympathetic system erection is mainly mediated by parasympa-thetic fibres, while sympathetic fibres...

Pathogenesis of CRC in IBD

The pathogenesis of CRC in IBD is poorly understood. However, several lines of evidence suggest that the pathobiology is different than sporadic CRC 1. the mean age of developing CRC in the setting of IBD is lower than sporadic CRC 40-50 vs. 60 years . 2. Dysplasia in UC is preceded by a long history of chronic inflammation and can be found at distant sites from the cancer. In contrast, dysplasia in sporadic CRC is usually associated with a discrete polyp without inflammation. 3. Mutations in...

Indications

The choice of the ideal surgical procedure for treating these patients is based upon the following considerations - the need of definitive treatment with a one-stage procedure that allows a complete removal of the diseased tissue and avoids the risk of cancer. - The possibility of restoring the anatomy as well as the bowel function and the faecal continence. - The outcome and the complications of different surgical procedures. - The patient's skills in managing the new condition and coping with...

Restorative Proctocolectomy

Laparoscopic Restorative Proctocolectomy

After placement of trocars and survey of the abdomen, complete mobilisation of the intraabdominal colon and terminal ileum up to the inferior border of the duodenum is accomplished. The distal ileum and mesenteric vessels are divided intracor-poreally. With the patient in Trendelenburg position, the rectum is circumferentially dissected down to the pelvic floor and transected with an articulate linear stapler at a level confirmed by digital examination. Fig. 12. Laparoscopic total colectomy...

FAP History Through a Patients Story

Genetic Tree

Gian Gaetano Delaini, Gianluca Colucci, Filippo Nifosi This is the story of Rosa Gallo, a young and bright student of medicine, who died of Gardner's syndrome at 21 years of age this story allows us to more easily explain the history of the disease, the various aspects of which aetiology, clinical history, diagnostic and therapeutical approach are extensively covered in several chapters of this book. Rosa Gallo was born on 6 August 1982, second born of the Gallo family, 4 years younger than the...

Genetics of Dysplasia

Although several other studies have evaluated immunohistochemical findings in these two groups of lesions DALM vs. sporadic adenoma , none have been shown to be useful in this differential diagnosis Table 4. Immunohistochemistry in DALM vs. sporadic adenoma Table 4. Immunohistochemistry in DALM vs. sporadic adenoma 25,26 . However, some investigators have suggested that IBD-associated adenoma-like DALMs has a higher degree of p53, and a lower degree of nuclear beta-catenin and bcl-2 staining in...

Bone Disease in IBD

Reduced bone mineral density BMD is frequently associated with Crohn's disease CD . Early studies have described a high prevalence of osteopenia a T-score of -1 or lower and osteoporosis a T-score of -2.5 or lower in inflammatory bowel disease IBD . Uncontrolled studies gave a prevalence of severe demineralisation determined by dual-energy absorp-tiometry Z-score of lower than -2 or T-score of lower than -2.5 that ranged from 18 to 42 , while larger studies with a healthy control group showed...

Stapled Ileal Pouch Anal Anastomosis

Ileal Pouch Anvil

Performing stapled ileal J-pouch anal anastomosis is by far the easiest method with respect to mesenteric length, because in this situation, the transanally placed stapler pushes the perineum towards the abdomen and small-bowel mesentery, reducing the length needed by several centimeters compared to hand-sewn techniques. Purse string sutures are not reliable and frequently are placed incorrectly. Because of this, incomplete doughnuts are common. I prefer to use a triple-staple approach, in...

Nnsteroidal Ati Inflammatory gents for Colon Cancer Prevention

Colon cancer prevention has now focused on novel targeted therapies, such as non-steroidal anti-inflammatory agents NSAIDs . Aspirin, an inhibitor of COX-1 and -2, has been studied in several large randomised studies, but the effect on colorectal cancer prevention is unclear. The US Physician's Health Study, which enrolled 22 071 physicians as participants, reported that aspirin had no effect on the incidence of polyps or colon cancer 3 . However, Baron et al. conducted the Aspirin Folate Polyp...

Anal Skin Tags and Haemorrhoids

Skin Tags After Hemorrhoids

Anal skin tags are typically asymptomatic and present problems only when they interfere with perianal hygiene Fig. 5 . They are more prominent with active intestinal disease. Approximately 25 resolve spontaneously, generally after remission of concomitant bowel disease. These tags should not be removed Fig. 5. Anal tags with ulceration and tissue inflammation Fig. 5. Anal tags with ulceration and tissue inflammation because that may result in an unhealed wound, a chronic ulcer or perianal...

Hull T.l.1996 Work On Ileostomy

Schraut WH, Medich DS 1997 Crohn's disease. In Greenfield LJ, Mulholland M, Oldham KT et al eds Surgery scientific principles and practice, 2nd edn. Lippincott, Philadelphia 2. Kodner IJ 1997 Perianal Crohn's disease. In Allan RN, Rhodes JM, Hanauer SB et al eds Inflammatory bowel diseases, 3rd edn. Churchill Livingstone, New York, p 863 3. Platell C, Mackay J, Collopy B et al 1996 Anal pathology in patients with Crohn's disease. Aust N Z J Surg 66 5-7 4. Solomon MJ 1996 Fistulae and...

Peculiar Aspects of Gastroenteric Extra Colonic Manifestations of FAP

Among the possible extra-colonic manifestations are upper gastroenteric lesions, stomach polyps 25-60 of the patients and duodenal polyps 24-73 19-21 . Hyperplastic polyps are commonly observed at a gastric level, whereas at a duodenal level and in the Vater's ampulla we mostly have real adenomas which are also subject to the rule of adenoma-carcinoma progression. Therefore, periodic endoscopic surveillance of the upper gastroenteric tract with possible removal of duodenal adenomas is...

Ultrasonographic Assessment of Perianal Crohns Disease

Puborectalis Muscle

Accurate identification of all loculate purulent areas and definition of the anatomy of the primary fistulous tract, secondary extensions and internal opening is crucial for the treatment plan. EAUS has been demonstrated to be a very helpful diagnostic tool in accurately assessing all fistula or abscess characteristics 8-11, 16, 17 . Ultrasound examination with the 2050 transducer is generally started using 13 MHz, changing to 12 MHz or 9 MHz to optimise visualisation of the deeper structures...

Flogistic and Fistulous Disease

Flogistic mass is a frequent finding in Crohn's patients, in particular in recurrent disease. Large palpable mass per se, especially if associated with complex fistulous disease or with a frozen abdomen, are often considered to be a contraindication to laparoscopy 4, 7, 9 10 , whereas a mininvasive approach is considered possible even after previous multiple surgeries 11, 12 . When a flogistic mass is present with thickened mesentery, the size of the minilaparotomy depends on the size of the...

NSAIDs and Desmoid Tumours

Several reviews 51-53 have summarized the intriguing and accumulating evidence that nonsteroidal anti-inflammatory drugs NSAIDs have potential as anti-cancer drugs. NSAIDs have been shown experimentally to stimulate apoptosis and to inhibit angiogenesis, two mechanisms that help to suppress malignant transformation and tumour growth. The mechanism of action common to NSAIDs is the inhibition of cyclooxygenase COX enzymatic conversion of the polyunsaturated fatty acid arachi-donic acid produced...

Ureteral Obstruction

Retroperitoneal Fibrosis Ultrasopund

This event is not rare and in most cases is not secondary to renal calculi. Although some signs of unilateral renal stasis have been demonstrated in almost 50 of IBD patients, who for various reasons have an intravenous pyelogram 83 , the reported incidence of ureteral obstruction with associated hydronephrosis is 3.1-14.3 in patients with CD 1, 3, 6, 84-86 and 6.8 in those with UC 84 . However, these percentages might be underestimated, considering that this condition is often asymptomatic or...

Definition and Classification of Dysplasia in Ulcerative Colitis

Dysplasia is defined as an unequivocal neoplastic change that is intraepithelial and within confinement of the gland basement membrane or as an unequivocal neoplastic alteration of the colonic epithelium. It may be a marker of carcinoma or may itself be malignant and associated with invasion into the underlying tissue 8 . It is important to realise that, for a very important and practical reason, diagnosing colonic dysplasia is one of the most challenging exercises that the surgical pathologist...

Anal Fistulae

Anal Fistula Drainage

Corman observed that, More surgeons' reputations have been impugned because of problems with fistula operations than from any other operative procedure 47 . In general, anal fistulae present symp-tomatically Fig. 6 . In Crohn's disease, they have the reputation of being difficult to treat with a high rate of recurrence. Patients are more concerned with postoperative incontinence, even if minor. Many authors advise the most cautious attitude in regards to surgical treatment 12, 18, 22, 47 ....

Recto Vaginal Fistula

Colocutaneous Fistula

The development of fistulae is a common complication of Crohn's disease CD . The lifetime risk of fistula development in patients with CD has typically been reported to range from 20 to 40 . The reported incidence of fistulizing CD from referral-based case series ranged from 17 to as much as 85 1-3 . The probability of internal fistulae was particularly high in patients with perianal disease who presented a relative risk of 3.4 compared to patients with different localizations 4 . Over time,...

Perianal Abscess

Intersphincteric Fistula

Perianal disease is an important and distinguishing feature of Crohn's disease CD . The incidence of perianal disease in patients with CD varies from 3.8 to 81 in different series 1, 2 . While perianal lesions occur more often in patients with colonic disease than in patients with small intestinal disease 2 , 5 of patients with anorectal CD do not have proximal disease. Clinical features include hypertrophic skin tags, ulceration Fig. 1 , perianal abscesses and fistulae Figs. 2 and 3 ,...

The Voluminous Mass was a Desmoid Tumour

Desmoid from the Greek desmos, which means tendon like tumours are begnin tumours arising from the muscle-aponeurotic structures 25 . They are usually well differentiated but with an aggressive behaviour. Even if they have no metastatic potential, they can locally infiltrate the adjacent structures, leading to morbility mortality because of the deformity resulting from the pressure or obstruction of vital structures organs 26-28 . They represent 0.03 of all neoplasies 29 but this incidence...

Stricturoplasties Notes on Surgical Technique

Heineke Mikulicz Strictureplasty

The first description of the use of stricturoplasty dates back to 1977 when Katariya, an Indian surgeon, published its use for the treatment of multiple tubercular stenoses in a series of nine patients 35 . In 1982, Lee and Papaioannou published the first results about the use of the strictureplasty technique in nine patients with CD 36 . Since then, many techniques were proposed on how to perform stricturoplasties. Surgical technique for this kind of operation must be very strict. After...

Fissure or Ulcers

Fissure Disease

Anal fissures in perineal Crohn's disease are classically deep, indolent, relatively painless and eccentrically located Fig. 4 but most Crohn's related fissures are in the midline. Fig. 3. Abscess in perineal Crohn's disease Fig. 3. Abscess in perineal Crohn's disease Fig. 4. Ulceration located at 1 o'clock lithotomy position with granulation tissue Fig. 4. Ulceration located at 1 o'clock lithotomy position with granulation tissue

Restorative Proctocolectomy Ileo Pouch Anal Anastomosis IPAA

The interest in IRA may well have declined with the advent of proctocolectomy and the ileo pouch-anal anastomosis IPAA . IPAA or restorative procto-colectomy, i.e. construction of a reservoir of distal ileum and an ileo pouch-anal anastomosis is the current most popular option for surgical treatment of ulcerative proctocolitis. There is no stoma or need for an external bag and the normal route of defecation is preserved, i.e. a normal body image. It has become the first choice operation to be...

Desmoid Tumors

Desmoid tumors DTs are benign fibrous growths which do not metastasize, but tend to invade locally. Although rare in the general population, DTs are not rare in FAP. They may arise in musculoaponeurotic structures throughout the body, but are most common in the abdomen. Desmoid tumors DTs affect between 4 and 20 of FAP patients. Within 10 years after colectomy, the cumulative risk of developing DTs is 16 61 , and the cumulative lifetime risk is 21 62 . The peak incidence is between 28 and 31...

Rectus Abdominis Myocutaneous Flap

Gracilis Myocutaneous Flaps

This technique was described by Taylor et al. in 1983 35 . It is an excellent method for closing a large perineal defect. Based on the inferior epigastric artery and vein, it may be passed into the pelvis to close the pelvic floor and fill the dead space. It is best employed pro-phylactically in high risk patients at the time of proc-tectomy when potential perineal wound problems are anticipated 17 , or at the time of abdominoperineal excision for a large neoplasm 34 when extensive perineal...

Gluteus Maximus Muscle and Musculocutaneous Flap

Gluteus Maximus Flap

The gluteus maximus muscle is one of the largest muscles in the body. Its principle actions are to extend the thigh and assist in its lateral rotation, steady the thigh and assist in raising the trunk from the flexed position. It has a dual blood supply from the superior and inferior gluteal vessels. The inferior gluteal artery and posterior cutaneous nerve of the thigh supply the inferior portion of gluteus maximus and the skin of the posterior thigh. Excision of the lower aspect of the...

Fulminant Colitis

Ulcerative Colitis With Necrotic

Fulminant colitis represents transmural extension of inflammation to the serosa and is manifested by abdominal tenderness in addition to systemic toxicity. Fulminant colitis with acute abdomen occurs in approximately 10 of patients with ulcerative colitis 5 . A definition of fulminant colitis is not equally accepted and lacks uniformity. To date, severity of the disease is based upon a composite of clinical and endoscopic criteria but no single system has been accepted. Truelove and Witts 6...

Gracilis Muscle Flap

Skeletal Muscle Blood Supply

Bartholdson and Hulten described the gracilis muscle flap for perineal reconstruction in 1975 29 . This fusiform muscle lies along the medial side of the thigh and knee and serves to adduct the thigh, and to flex and medially rotate the leg. It attaches proximal-ly at the body and inferior ramus of the pubic bone and distally to the superior part of the medial surface of the tibia. The dominant vascular pedicle of this flap is the medial femoral circumflex artery and vein that branches off the...

Conventional and Videolaparoscopic Treatment

When IPAA is performed for UC some technical questions are still debated, especially about the type of ileoanal anastomosis hand-sewn after mucosectomy or stapled without mucosectomy and the number of surgical stages one, two or three total colectomy, restorative proctectomy with IPAA, removal of protection ileostomy . In patients affected with FAP, total colectomy and IRA are performed in a single operation without any protection ileostomy, whereas IPAA is usually a two-stage technique with a...

Familial Adenomatous Polyposis

Duodenal Adenomatosis Fap

In these patients, the disease begins at the age of 8-10 years with a small number of colonic polyps, increasing progressively until the colon becomes studded with adenomas. Endoscopy mainly plays a diagnostic role Fig. 2 since colorectal cancer should be considered an inevitable consequence in the natural history of FAP, appearing approximately 15 years after the onset of the polyps. For this reason prophylactic proctocolectomy is the procedure of choice for this condition. After the...

Entero Urinary Fistula EUF

Entero Vaginal Fistula

It is well known that about one third of patients with CD have enteroenteric or enterocutaneous fistulas which are secondary to the characteristic transmural inflammation 58 . Fistulisation within the urinary system is also possible but it is much less common, occurring in 1-8 of cases 1, 3, 6,19, 59-62 . The majority of fistulas result from direct contact between inflamed terminal ileum and the bladder dome ileovesical fistula . Sometimes an intervening abscess is present and in this case it...