The multidisciplinary health care team in the management of stenosis in Crohn's disease.

BACKGROUND: Stricture formation is a common complication of Crohn's disease (CD), occurring in approximately one-third of all patients with this condition. Our aim was to summarize the available epidemiology data on strictures in patients with CD, to outline the principal evidence on diagnostic imaging, and to provide an overview of the current knowledge on treatment strategies, including surgical and endoscopic options. Overall, the unifying theme of this narrative review is the multidisciplinary approach in the clinical management of patients with stricturing CD. METHODS: A Medline search was performed, using "Inflammatory Bowel Disease", "stricture", "Crohn's Disease", "Ulcerative Colitis", "endoscopic balloon dilatation" and "strictureplasty" as keywords. A selection of clinical cohort studies and systematic reviews were reviewed. RESULTS: Strictures in CD are described as either inflammatory or fibrotic. They can occur de novo, at sites of bowel anastomosis or in the ileal pouch. CD-related strictures generally show a poor response to medical therapies, and surgical bowel resection or surgical strictureplasty are often required. Over the last three decades, the potential role of endoscopic balloon dilatation has grown in importance, and nowadays this technique is a valid option, complementary to surgery. CONCLUSION: Patients with stricturing CD require complex clinical management, which benefits from a multidisciplinary approach: gastroenterologists, pediatricians, radiologists, surgeons, specialist nurses, and dieticians are among the health care providers involved in supporting these patients throughout diagnosis, prevention of complications, and treatment

Correction to: Effects of immune suppression for transplantation on inflammatory colorectal cancer progression (Oncogenesis, (2018), 7, 6, (46), 10.1038/s41389-018-0055-5)

At the time of publication, the html version of this paper contained an error; the authors Imerio Angriman and Lucrezia Furian were not tagged as equally contributing authors. This has now been fixed in the html version of the paper, the PDF was correct at the time of publication. Erratum for Effects of immune suppression for transplantation on inflammatory colorectal cancer progression. [Oncogenesis. 2018

Anastomosis configuration and technique following ileocaecal resection for Crohn's disease: a multicentre study

A limited ileocaecal resection is the most frequently performed procedure for ileocaecal CD and different anastomotic configurations and techniques have been described. This manuscript audited the different anastomotic techniques used in a national study and evaluated their influence on postoperative outcomes following ileocaecal resection for primary CD. This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing elective ileocaecal resection for primary CD from June 2018 May 2019. Postoperative morbidity within 30 days of surgery was the primary endpoint. Postoperative length of hospital stay (LOS) and anastomotic leak rate were the secondary outcomes. 427 patients were included. The side to side anastomosis was the chosen configuration in 380 patients (89%). The stapled anastomotic (n = 286; 67%), techniques were preferred to hand-sewn (n = 141; 33%). Postoperative morbidity was 20.3% and anastomotic leak 3.7%. Anastomotic leak was independent of the type of anastomosis performed, while was associated with an ASA grade ≥ 3, presence of perianal disease and ileocolonic localization of disease. Four predictors of LOS were identified after multivariate analysis. The laparoscopic approach was the only associated with a reduced LOS (p = 0.017), while age, ASA grade ≥ 3 or administration of preoperative TPN were associated with increased LOS. The side to side was the most commonly used anastomotic configuration for ileocolic reconstruction following primary CD resection. There was no difference in postoperative morbidity according to anastomotic technique and configuration. Anastomotic leak was associated with ASA grade ≥ 3, a penetrating phenotype of disease and ileo-colonic distribution of CD

National variations in perioperative assessment and surgical management of Crohn's disease: a multicentre study

Aim: Crohn's disease (CD) requires a multidisciplinary approach and surgery should be undertaken by dedicated colorectal surgeons with audited outcomes. We present a national, multicentre study, with the aim to collect benchmark data on key performance indicators in CD surgery, to highlight areas where standards of CD surgery excel and to facilitate targeted quality improvement where indicated. Methods: All patients undergoing ileocaecal or redo ileocolic resection in the participating centres for primary and recurrent CD from June 2018 to May 2019 were included. The main objective was to collect national data on hospital volume and practice variations. Postoperative morbidity was the primary outcome. Laparoscopic surgery and stoma rate were the secondary outcomes. Results: In all, 715 patients were included: 457 primary CD and 258 recurrent CD with a postoperative morbidity of 21.6% and 34.7%, respectively. Laparoscopy was used in 83.8% of primary CD compared to 31% of recurrent CD. Twenty-five hospitals participated and the total number of patients per hospital ranged from 2 to 169. Hospitals performing more than 10 primary CD procedures per year showed a higher adoption of laparoscopy and bowel sparing surgery. Conclusions: There is significant heterogeneity in the number of CD surgeries performed per year nationally in Italy. Our data suggest that high-volume hospitals perform more complex procedures, with a higher adoption of bowel sparing surgery. The rate of laparoscopy in high-volume hospitals is higher for primary CD but not for recurrent CD compared with low-volume hospitals

Management of RLS in Children (Unique Features)

Restless legs syndrome (RLS) is a relatively common pediatric disease with an estimated prevalence of 2–4% in school-aged children and adolescents [1–4]. Often it is misdiagnosed and ignored by most pediatricians and general practitioners. The classical clinical presentation of a compelling urge to move the legs, often accompanied by uncomfortable dysesthesias, is the RLS presentation also in children. To make a diagnosis of RLS, this core of sensory-motor symptoms must be present at rest, at least temporarily relieved by movement, and most pronounced at night [5]. The exact prevalence of RLS in children is unknown, although one-third of adults with RLS are affected in childhood. Studies have reported that, in adults with RLS, 25% of them had onset of their symptoms between 10 and 20 years of age and 18% of them had onset before 10 years of age [2]. Pediatricians need to be aware of RLS because it may be common, and when untreated, can cause significant functional impairment. Possible causes of under-recognition include the mild and intermittent nature of the symptoms at younger ages

Health related quality of life after surgery for Crohn's disease.

Crohn\u2019s disease cannot be healed but just taken into remission. Intestinal obstruction and fistulization, lack of response to medical management and perianal disease are the most frequent indication for intestinal surgery. Why is it necessary to measure quality of life after surgery for Crohn\u2019s disease? Firstly, morbidity and mortality provide a partial and, very often, incomplete picture of outcome. Secondarily, nowadays, indications for surgery for Crohn\u2019s disease are broader and not limited to life saving procedures but in many cases they include chronic conditions such as failure of medical therapy, or poor quality of life on it self. Finally, quality of life is a more patient orientated measure of outcome that can give the patients\u2019 point of view about the procedure that is proposed. HRQL is a multi-dimensional concept which includes several dimensions based on biological and symptom variables. Disease-related worries and concerns about the disease on itself and its therapy reflect one of these dimensions and they are considered to be a major determinant of HRQL in patients with IBD. In fact, concerns about having surgery and having an ostomy bag have a relevant impact on HRQL of Crohn\u2019s disease patients and having surgery increases concerns about body stigma. The early impact of surgery on HRQL is an important component of the patient\u2019s decision regarding immediate and future surgery and understanding his or her recovery. Obviously, HRQL is expected to improve after operative procedures. In effect, in most of the studies, a significant improvement in HRQL early in the postoperative period was observed. Improvement, apparently, occurred irrespective of the disease activity measured with CDAI, the indication for surgery, type of procedure (abdominal or perineal), and history of previous surgery. On the contrary, the long-term impact of surgery on HRQL is more controversial. Some studies, mainly those performed with generic questionnaires, reported an improved HRQL while other (those performed with disease specific instruments) described a decreased HRQL. According to these authors, HRQL, apparently, depends mainly on the long-term disease activity

Pediatric insomnia: new insights in clinical assessment and treatment options

Sleep disorders in children can compromise quality of life of both children and families and chronic sleep deprivations is associated with poorer developmental outcome, overweight and behavioral disturbances. Clinicians should incorporate questions about sleep into their routine health assessment, and the assessment of insomnia should follow a medical approach primary and secondary contributing factors should be assessed, as well as maladaptive behaviors related to sleep. A careful examination of sleep/wake schedule, abnormal movements or behavior during sleep, and daytime consequences of sleep disruption or deprivation is mandatory. Sleeping environment, and bedtime routines should be examined to identify behavioral issues related to sleep. Polysomnography is not routinely indicated for children with insomnia, but actigraphy can give an objective estimation of sleep parameters. The Authors propose a new classification of pediatric insomnia, based on both genetic and clinical aspects, and suggest specific treatment options, including sleep hygiene, behavioral strategies and pharmacological treatment

L'insonnia in età evolutiva

The aim of the present work is to summarize recent advances in the field of clinical paediatric sleep medicine and to give tools for clinical assessment and treatment of paediatric insomnia. Bedtime problems and night awakenings are common cause of paediatric consultation and have an impact on quality of life of both child and family. Epidemiology, pathophysiology, clinical evaluation, sequelae, and treatment are described. Clinical tools for assessment and behavioural and pharmacological treatment are presente