Management of ruptured hepatocellular carcinoma:Implications for therapy

AIM:To assess the treatment and tumor-related variables associated with outcome after treatment of spontaneously ruptured hepatocellular carcinoma (HCC).METHODS: Patients with ruptured HCC were identif ied. The complications, mortality and survival were assessed. The relationship between tumor size and the severity of hemoperitoneum and between tumor size and grade were examined.RESULTS: From January 1993 to January 2008, 556 patients with HCC with or without cirrhosis were evaluated; of which, 16 (2.87%) presented with spontaneous rupture. All but 1 patient had cirrhosis. Twelve patients underwent surgical resection while 4 underwent trans-cutaneous arterial catheter embolization (TAE) (trans-cutaneous arterial embolization). Early mortality (<30 d) was 25% (4 of 16) and was inversely relatedto Child-Pugh score; 3 of the 4 early deaths occurred in patients treated with TAE with 1 of 12 occurring in the resected group. There was no correlation between tumor size and grade or between size and severity of hemoperitoneum.CONCLUSION: Tumor size did not correlate with severity of the hemoperitoneum. There was an inverse relationship between G1-G3 (grade of cellular differentiation) HCC and dimensions.

Acute appendicitis: What is the gold standard of treatment?

McBurney’s procedure represented the gold-standard for acute appendicitis until 1981,but nowadays the number of laparoscopic appendectomies has progressively increased since it has been demonstrated to be a safe procedure,with excellent cosmetic results and it also allows a shorter hospitalization,a quicker and less painful postoperative recovery.The aim of this editorial was to perform a review of the literature in order to address controversial issues in the treatment of acute appendicitis.

Perianal Crohn's disease: Is there something new?

Perianal lesions are common in patients with Crohn's disease, and display aggressive behavior in some cases. An accurate diagnosis is necessary for the optimal management of perianal lesions. Treatment of perianal Crohn's disease includes medical and/or surgical options. Recent discoveries in the pathogenesis of this disease have led to advances in medical and surgical therapy with good results. Perianal lesions in Crohn's disease remain a challenging aspect for both gastroenterologists and surgeons and lead to a greatly impaired quality of life for all patients affected by this disease. A multidisciplinary approach is mandatory to obtain the best results.

Persistence of high CD40 and CD40L expression after restorative proctocolectomy for ulcerative colitis

AIM: To focus on the role of CD40 and CD40L in their pathogenesis.METHODS: We analyzed by immunohistochemistry the CD40 and CD40L expression in the pouch mucosa of 28 patients who had undergone RPC for UC, in the terminal ileum of 6 patients with UC and 11 healthy subjects. We also examined by flow cytometry the expression of CD40 by B lymphocytes and monocytes in the peripheral blood of 20 pouch patients, 15 UC patients and 11 healthy controls.RESULTS: Ileal pouch mucosa leukocytes presented a significantly higher expression of CD40 and CD40L as compared to controls. This alteration correlated with pouchitis, but was also present in the healthy pouch and in the terminal ileum of UC patients. CD40 expression of peripheral B lymphocytes was significantly higher in patients with UC and pouch, respect to controls. Increased CD40 levels in blood B cells of pouch patients correlatedwith the presence of spondyloarthropathy, but not with pouchitis, or inflammatory indices.CONCLUSION: High CD40 expression in the ileal pouch mucosa could be implied in the pathogenesis of pouchitis following proctocolectomy for UC, whereas its increased levels on peripheral blood B lymphocytes are associated with the presence of extraintestinal manifestations.

Antioxidative potential of a combined therapy of anti TNFα and Zn acetate in experimental colitis

AIM:To evaluate whether combination therapy with antitumour necrosis factor α (TNFα) antibody and Zn acetate is beneficial in dextran sodium sulphate (DSS) colitis.METHODS:Colitis was induced in CD1-Swiss mice with 5% DSS for 7 d.The experimental mice were then randomised into the following subgroups:standard diet + DSS treated (induced colitis group);standard diet + DSS + subcutaneous 25 μg anti-TNFα treated group;Zn acetate treated group + DSS + subcutaneous 25 μg anti-TNFα;standard diet + DSS + subcutaneous 6.25 μg anti-TNFα treated group and Zn acetate treated group + DSS + subcutaneous 6.25 μg anti-TNFα.Each group of mice was matched with a similar group of sham control animals.Macroscopic and histological features were scored blindly.Homogenates of the colonic mucosa were assessed for myeloperoxidase activity as a biochemical marker of inflammation and DNA adducts (8OH-dG) as a measure of oxidative damage.RESULTS:DSS produced submucosal erosions,ulcers,inflammatory cell infiltration and cryptic abscesses which were reduced in both groups of mice receiving either anti-TNFα alone or combined with zinc.The effect was more pronounced in the latter group (vs Zn diet,P < 0.02).Myeloperoxidase activity (vs controls,P < 0.02) and DNA adducts,greatly elevated in the DSS fed colitis group (vs controls,P < 0.05),were significantly reduced in the treated groups,with a more remarkable effect in the group receiving combined therapy (vs standard diet,P < 0.04).CONCLUSION:DSS induces colonic inflammation which is modulated by the administration of anti-TNFα.Combining anti-TNFα with Zn acetate offers marginal benefit in colitis severity.

Health related quality of life after surgery for colonic diverticular disease

Diverticular disease(DD) of the colon is very common in developed countries and is ranked the fifth most important gastrointestinal disease worldwide.The management of acute diverticulitis without perforation and peritonitis is still debated.Health related quality of life(HRQL),subjectively perceived by patients,is becoming a major issue in the evaluation of any therapeutic intervention,mainly in patients with chronic disease.To date only a few published studies can be found on Medline examining HRQL in patients with DD.The aim of this study was to review the impact of surgery for DD on HRQL.All Medline articles regarding HRQL after surgery for colonic DD,particularly those comparing different surgical approaches,were reviewed.DD has a negative impact on HRQL with lower scores in bowel function and systemic symptoms.Both surgery-related complications and disease activity have a significant impact on patients' HRQL.While no signif icant differences in HRQL between different operations for DD in non-randomized studies were revealed,the only prospective double-blind randomized study that compared laparoscopic and open colectomy found that patients undergoing laparoscopic colectomy had signif icantly reduced major postoperative complication rates and subsequently had better HRQL scores.Formal assessment of HRQL could be a good instrument in the selection of appropriate patients for elective surgery as well as in the assessment of surgical outcome.