Inflammatory Bowel Diseases and Thrombosis. An Update. Review Article.

Introduction: Inflammatory bowel diseases (IBD) are a group of affections characterized by a chronic inflammation of the mucosae of the digestive tract and primarily include Crohn\u2019s Disease (CD) and Ulcerative Colitis (UC). Although much has already been studied, aetiology and pathomechanisms are still unclear. IBD patients are at risk of many complications including the risk of thromboembolic events. Thrombotic complications in this kind of patients have already been recognised and demonstrated although further considerations have to be made regarding the incidence of such kind of events. Aim and Methods: This article is intended to resume the state of the art on venous thromboembolic complications (VTE) which can affect these patients by heavily increasing morbidity and mortality rates. A literature search was conducted using Medline, Embase,Ovid Journals, and Science Direct. The keywords were \u201cInflammatory Bowell Disease\u201d, \u201cCrohn\u2019s Disease\u201d, \u201cUlcerative Colitis\u201d, \u201cThrombosis\u201d and \u201cInflammatory Bowel Diseases and Thrombosis\u201d. Results: Very little is known in this respect and as extended RCTs (randomised controlled studies) have not yet been conducted it is not possible to clearly define what the clinical approach to prevention towards this complication must be. Recent studies evidence a strong correlation between IBD and VTE complications such as deep venous thrombosis (DVT) and pulmonary embolism (PE). Available prophylaxis and treatment options include pharmacological anticoagulant therapy (LMWH-Low Molecular Weight Heparin, Fondaparinux and UH-Unfractionated Heparin) and mechanical prophylaxis. Treatment options in case of acute VTE include anticoagulant therapy, fibrinolytic agents and in selected non-responsive cases vascular surgery. Conclusions: As IBD patients have an increased risk of VTE complications, prophylaxis for VTE should be recommended in all patients who do not show contraindications to treatment

Elective surgery for ulcerative colitis : ileo-rectal anastomosis or restorative proctocolectomy. An Update

Ann Ital Chir. 2019;90:565-573. Elective surgery for ulcerative colitis, ileo-rectal anastomosis or restorative proctocolectomy An Update. Fornaro R, Casaccia M, Caristo G, Batistotti P, Di Maira L, Atzori G, Oliva A, Stratta E, Razzore A, Caratto M, Caratto E, Giovinazzo D, Frascio M. BACKGROUND: Despite advances in the medical management of Ulcerative Colitis (UC), surgery is required in about a third of patients. AIMS AND METHODS: A review of the literature of the last 20 years was conducted in order to analyze the results of Ileo-Rectal Anastomosis (IRA) and of Ileal Pouch-Anal Anastomosis (IPAA) in the treatment of mild-to-moderate UC. Postoperative complications, functional results and the risk of cancer were analyzed in each of the two groups of patients. RESULTS: In IRA group postoperative morbidity is low, varying from 8 to 28%. The risk of urinary and sexual dysfunction are rare and fertility rates are higher, compared to IPAA. The cumulative probability of success (working IRA) is 84% at 5 years and 51-69% at 10 years. The postoperative morbidity of IPAA is higher; dehiscence and pelvic sepsis were observed respectively in 9.5% and in 5.5%. A sexual dysfunction is present in 3.4%. In 18.8% occurs pouchitis. The risk of failure of the pouch is 6.8% and increased to 8.5% after 5 years. The risk of cancer is higher after IRA than after IPAA, with a cumulative risk at 20 years of 6-14% and 4.2% respectively. DISCUSSION: The choice between IPAA or IRA is based upon patient's preference and clinical criteria (malignancy or sphincter injury). IPAA, intervention of choice, is burdened by a higher rate of complications, such as anastomotic leak with pelvic sepsis and subsequent functional pouch failure, pouchitis, infertility in young women, lesions of the pelvic nerves and portal vein thrombosis. There have been reports of cancer not only in the anal transitional zone, but also in the same pouch, either after mucosectomy that after stapled anastomosis. IRA is less invasive than IPAA and postoperative complications are lower. Does not require dissection of the pelvic and presents no risk of injury of the nerves of the urogenital sphere. The long-term results of the IRA are generally satisfactory and most of the patients stated that after the intervention improve both the health status and quality of life. CONCLUSION: Today IPAA is the gold standard. The IRA is indicated in selected patients where they meet the following requirements: normal sphincter tone, absence of severe perineal disease, rectum does not actively involved by the disease, absence of dysplasia or cancer. It is also indicated in patients who refuse an ileostomy and it can be proposed as a possible interim procedure in young women, because it does not need a pelvic dissection and because the risk of infertility is minimal or absent when compared to IPAA. Because the risk of cancer is higher, patients undergoing IRA must be adequately informed about the risk, as well as recurrent proctitis, also of cancer, and must fully understand the need for surveillance and accept at least annual endoscopy with rectal biopsies; if these conditions are not met, patients should not be candidates for IRA. KEY WORDS: IPAA, IRA, Surgical treatment, Ulcerative Colitis. PMID: 3192917