Clinical Outcome in Acute Small Bowel Obstruction after Surgical or Conservative Management

Background: Small bowel obstruction (SBO) is characterized by a high rate of recurrence. In the present study, we aimed to compare the outcomes of patients managed either by conservative treatment or surgical operation for an episode of SBO. Methods: The outcomes of all patients hospitalized at a single center for acute SBO between 2004 and 2007 were assessed. The occurrence of recurrent hospitalization, surgery, SBO symptoms at home, and mortality was determined. Results: Among 221 patients admitted with SBO, 136 underwent a surgical procedure (surgical group) and 85 were managed conservatively (conservative group). Baseline characteristics were similar between treatment groups. The median follow-up time (interquartile range) was 4.7 (3.7-5.8) years. Nineteen patients (14.0%) of the surgical group were hospitalized for recurrent SBO versus 25 (29.4%) of the conservative group [hazard ratio (HR), 0.5; 95% CI, 0.3-0.9]. The need for a surgical management of a new SBO episode was similar between the two groups, ten patients (7.4%) in the surgical group and six patients (7.1%) in the conservative group (HR, 1.1; 95% CI, 0.4-3.1). Five-year mortality from the date of hospital discharge was not significantly different between the two groups (age- and sex-adjusted HR, 1.1; 95% CI, 0.6-2.1). A follow-up evaluation was obtained for 130 patients. Among them, 24 patients (34.8%) of the surgical group and 35 patients (57.4%) of the conservative group had recurrent SBO symptoms (odds ratio, 0.4; 95% CI, 0.2-0.8). Conclusions: The recurrence of SBO symptoms and new hospitalizations were significantly lower after surgical management of SBO compared with conservative treatment

Perforated Meckel's diverticulitis complicating active Crohn's ileitis: a case report

<p>Abstract</p> <p>Introduction</p> <p>In Crohn's disease, the extension of active terminal ileitis into a Meckel's diverticulum is possible, but usually has no impact on clinical decision-making. We describe an original surgical approach in a young woman presenting with a combination of perforated Meckel's diverticulitis and active Crohn's ileitis.</p> <p>Case presentation</p> <p>We report the case of a 22-year-old woman with Crohn's disease, who was admitted for abdominal pain, fever and diarrhoea. CT scan demonstrated active inflammation of the terminal ileum, as well as a fluid collection in the right iliac fossa, suggesting intestinal perforation. Laparoscopy was performed and revealed, in addition to extensive ileitis, a 3 × 3 cm abscess in connection with perforated Meckel's diverticulitis. It was therefore possible to avoid ileocaecal resection by only performing Meckel's diverticulectomy; pathological examination of the surgical specimen revealed the presence of transmural inflammation with granulomas and perforation of the diverticulum at its extremity.</p> <p>Conclusion</p> <p>Crohn's disease of the ileum may be responsible for Meckel's diverticulitis and cause perforation which, in this case, proved to be a blessing in disguise and spared the patient an extensive small bowel resection.</p

Differential Pathogenic Th17 Profile in Mesenteric Lymph Nodes of Crohn's Disease and Ulcerative Colitis Patients

The drug targets IL23 and IL12 regulate pathogenicity and plasticity of intestinal Th17 cells in Crohn's disease (CD) and ulcerative colitis (UC), the two most common inflammatory bowel diseases (IBD). However, studies examining Th17 dysregulation in mesenteric lymph nodes (mLNs) of these patients are rare. We showed that in mLNs, CD could be distinguished from UC by increased frequencies of CCR6+CXCR3−RORγ+Tbet−CD4+ (Th17) memory T cells enriched in CD62Llow effector memory T cells (TEM), and their differentially expressed molecular profile. Th17 TEM cells (expressing IL17A, IL17F, RORC, and STAT3) displayed a higher pathogenic/cytotoxic (IL23R, IL18RAP, and GZMB, CD160, PRF1) gene signature in CD relative to UC, while non-pathogenic/regulatory genes (IL9, FOXP3, CTLA4) were more elevated in UC. In both CD and UC, IL12 but not IL23, augmented IFNγ expression in Th17 TEM and switched their molecular profile toward an ex-Th17 (Th1*)-biased transcriptomic signature (increased IFNG, and decreased TCF7, IL17A), suggesting that Th17 plasticity occurs in mLNs before their recruitment to inflamed colon. We propose that differences observed between Th17 cell frequencies and their molecular profile in CD and UC might have implications in understanding disease pathogenesis, and thus, therapeutic management of patients with IBD

Management of obstructive and perforated colorectal cancer

Colorectal cancer frequently presents with obstruction or perforation at the time of diagnosis, and requires urgent surgery. Various surgical and endoscopic approaches are available that minimize the risk of complications related to emergency colorectal operations and optimize the oncological outcome for the patients. The surgeon has to make clinically and oncologically adequate decisions, ranging from diverting colostomy to partial or total colectomy in a one-stage procedure or multistage interventions. The endoscopic insertion of a self-expanding metallic stent is an option either as a definitive procedure in palliative conditions or as a bridge to safer elective surgery. In this article, we discuss the current surgical and endoscopic treatments of complicated colorectal cancer and propose an algorithm for the management of patients with obstructive tumors

Gastrointestinal mucormycosis after abdominal aortic aneurysm repair and prolonged hospitalization: A case report and review of the literature

Introduction: Mucormycosis is a rare fungal infection typically affecting immunocompromised hosts. One form of the disease affects the gastrointestinal tract. Presentation of case: We present the case of a 70-year old patient with no recognized risk factors that developed gastrointestinal mucormycosis after urgent abdominal aortic aneurysm repair. Discussion: There are several risk factors for this infection, such as hematological malignancies, solid organ or stem cell transplants and diabetes. The infectious agent causes thrombosis and necrosis of involved tissues and organs and carries a high mortality rate. Conclusion: Mucormycosis is an opportunistic infection which can sometimes affect the gastrointestinal tract. A high index of suspicion is necessary in order to make an early diagnosis and promptly start an appropriate treatment regimen

Metastatic rectal neuroendocrine tumor presenting as an inguinal mass: A case report and review of literature

Introduction: Neuroendocrine tumors (NET) are a heterogeneous group of rare carcinomas that most often manifest along the gastrointestinal tract. Some of these tumors have the ability to secrete vasoactive peptides and hormones. Presentation of case: The present report describes the case of a previously healthy 52-year old man who presented with a painful right inguinal mass. Upon surgical exploration, a lymph node metastasis of a high-grade NET was found. Further investigations revealed a rectal NET with pulmonary, pelvic and penile metastases. The patient was treated with 6 cycles of carboplatin and etoposide. Although initial follow-up imaging after 3 cycles of chemotherapy revealed stable disease, there was progression of the metastases after completion of systemic treatment. Second and third-line chemotherapy regimens were instituted along with pelvic and whole-brain radiation therapy extending the patient’s survival to 18 months after the initial diagnosis. Discussion: This case highlights the aggressive nature high-grade NETs as described in the current literature. Treatment modalities of colorectal NETs include local excision for non-metastatic disease and systemic palliative chemotherapy for advanced disease. However, there are no controlled trials in favor of palliative chemotherapy. Conclusion: Rectal NETs are rare tumors which often have an atypical presentation or present in advanced stages. Currently, surgical options exist for local disease while treatment modalities for more advanced disease is still under investigation

La pancréatite aiguë ou la nécessité d'anticipation

Acute pancreatitis is a potentially lethal inflammatory disease with an increased incidence and a decreased mortality rate. The main etiologies are biliary stones and alcohol abuse. The therapeutic approach consists of the elimination of the cause, the hemodynamic and respiratory supports and the treatment of the complications. Moreover, severe acute pancreatitis requires a collaboration between surgeons, radiologists, gastroenterologists and intensive care physicians. The administration of prophylactic antibiotics and the early oral nutritional support are still controversial. In summary, the anticipation in diagnosis, etiology, classification of the severity and early reanimation are needed for an optimal treatment of this complex disease

Spontaneous dissection of the superior mesenteric artery and the right hepatic artery: a case report

INTRODUCTION: Isolated spontaneous dissection of the superior mesenteric artery is a very rare condition. Endovascular stent placement has been proposed recently for selected cases, which has led to some good clinical results. CASE PRESENTATION: We report a case of spontaneous dissection of the superior mesenteric artery spreading to the origin of a right hepatic artery in a 48-year-old Chinese man. He benefited from the placement of an endovascular stent that yielded excellent results. CONCLUSION: Endovascular stent placement is a good alternative treatment for dissection of the superior mesenteric artery. We propose an algorithm for the management of this rare condition

A Functional GM-CSF Receptor on Dendritic Cells Is Required for Efficient Protective Anti-Tumor Immunity

Dendritic cells (DC) play a major role during the priming phase of anti-tumor immunization, as they are required for an efficient tumor-associated antigens presentation. At least one dendritic cell-based therapy has already been successfully approved by regulators for clinical application in prostate cancer patients. Moreover, DC development is dependent on the granulocyte macrophage colony stimulating factor (GM-CSF), a cytokine that has been successfully used as a potent inducer of anti-tumoral immunity. To better understand the relation between DC and GM-CSF in anti-tumor immunity, we studied the DC function in mice lacking the cytokine receptor common subunit beta (βc-/-) for GM-CSF, IL-3 and IL-5 and immunized with irradiated tumor cells. Such immunization induces a protective, specific tumor immunization in wild-type mice, while βc-/- mice failed to mount an immune response. Upon in vitro stimulation, DC from βc-/- mice (DCβc-/-) are unable to undergo a full maturation level. In vivo experiments show that they lack the ability to prevent tumor growth, in contrast to DCWT. Moreover, matured DCWT rescued immunization in βc-/- mice. DC maturation is dependent on a functional pathway involving GM-CSF signaling through a biologically functional receptor. These findings may contribute to new strategies for efficient anti-tumor immunotherapies