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Background: Inflammatory bowel disease (IBD) and colorectal surgery are risk factors for deep venous thrombosis (DVT). The aim of this prospective study was to evaluate the effectiveness of standardized prophylactic low molecular weight heparin (LMWH) therapy in patients who underwent surgery for ulcerative colitis (UC) and Crohn's disease (CD)., Patients and Methods: Since 1999 all patients operated on for colorectal diseases in our institute have received 4,000 IU/day LMWH from the day of operation to discharge. The complete series of patients who had major colorectal surgery from 1999 until 2006 were reviewed for overt DVT episodes. Furthermore, 60 consecutive patients who were admitted for surgery for IBD were prospectively enrolled in the 2004-2006 period. Each patient underwent venous color Doppler ultrasound scan at admission and at discharge. Demographic data, disease activity, and clotting parameters were collected. Data were analyzed with Spearman's correlation test, multiple regression, and receiver operating characteristics (ROC) curves analysis., Results: The rate of DVT in UC patients was significantly higher than in colorectal cancer patients (p = 0.009), and the odds ratio (OR) for postoperative DVT in UC patients was 7.4 (95% CI 1.4-44.4; p = 0.017). Female gender, UC diagnosis, active rectal bleeding, aPTT value, aCL IgM, abeta2 IgM, and pANCA levels significantly correlated with postoperative DVT. At multivariate analysis only aCL IgM levels were found to be independently associated with postoperative DVT (p = 0.05)., Conclusions: In conclusion, our study showed that prophylactic therapy with 4,000 IU/day LMWH was not completely effective for the prevention of postoperative DVT in patients with CD, and even less so in those with UC. In these patients, a more tailored prophylactic therapy should be considered, and further randomized controlled trials testing the effectiveness of different prophylactic protocols would be advisable. Furthermore, aCL IgM serum levels might be helpful in identifying IBD patients who are at higher risk of postoperative DVT.

Background: ACTH-independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushing's syndrome. Bilateral adrenalectomy is considered the treatment of choice, with subsequent lifetime steroid replacement, but unilateral adrenalectomy has been recently proposed to reduce the secreting tissue. This prospective study was designed to evaluate the long-term results of unilateral adrenalectomy in AIMAH concerning the main laboratory and clinical abnormalities and the patient's quality of life., Methods: Seven consecutive patients with confirmed AIMAH underwent unilateral adrenalectomy of the largest gland. ACTH and cortisol levels, arterial blood pressure (BP), glycometabolic parameters, and patient's subjective perception of health-related quality of life (by the SF-36 questionnaire) were measured preoperatively and postoperatively., Results: No surgery-related morbidity occurred. One patient with a large contralateral adrenal enlargement required a completion adrenalectomy after 7 months because of persistent hypercortisolism. At a median follow-up of 53 (range, 27-68) months, the remaining six patients were cured, because serum and urinary free cortisol levels significantly decreased and ACTH increased, thus regaining the normal range. Both systolic and diastolic BP levels significantly reduced: 50% of patients definitively became normotensive, and the remaining patients reduced the need for antihypertensive treatment; 40% of patients suffering from preoperative diabetes were cured, whereas 40% reduced the need for hypoglycemizing drug. SF-36 evaluation of the health-related quality of life confirmed a significant amelioration., Conclusions: Unilateral adrenalectomy of the largest gland can be an effective and safe treatment for AIMAH in case of asymmetric involvement. It may achieve long-term remission of Cushing's syndrome and improve BP values, glycemic control, and patient's quality of life.

Background/aims: Anastomotic recurrence after bowel resection is a major problem in Crohn's disease (CD) surgery. The aims of this retrospective study are to assess the role of anastomotic configuration, the type of suture and the type of surgical approach (laparoscopy-assisted vs laparotomy) in CD recurrence. Secondary end points were to identify any possible predictor that would help the selection of patients for medical prophylaxis., Materials and Methods: In this retrospective study, we enrolled 141 consecutive patients who had undergone ileocolonic resection for CD. Univariate actuarial analysis was performed according to demographic, clinical and surgical predictors. Variables that resulted to be significant at the univariate analysis were included in two multivariate Cox proportional hazards models that analyzed symptomatic and surgical recurrence, respectively., Results: In the long-term, handsewn side-to-side anastomosis reported a significantly lower surgical recurrence rate than stapled end-to-side (p < 0.05). At multivariate analysis, anastomosis type, surgical and intestinal complications (p < 0.01) and age at CD onset (p < 0.05) resulted to be significant predictors for re-operation for CD recurrence. Multivariate analysis showed that surgical complication was also a significant predictor of symptomatic recurrence., Conclusions: Side-to-side anastomosis configuration seems to delay re-operation and can be assumed as the standard configuration in ileocolonic anastomosis in CD. Post-operative complications and young age at disease onset might be a signal of aggressive CD that may warrant prophylactic pharmacological therapy.

Background and Aims: B1a lymphocytes (CD5+) are the major contributors of natural antibodies (Ab) implicated in the initial protection against several infections. The aim of this study was to assess the expression of these cells in the peripheral blood of ulcerative colitis (UC) patients who underwent restorative proctocolectomy (RPC) and others who were not operated on., Materials and Methods: The blood concentration of CD5+ B cells was analysed by three-colour flow cytometry. Blood was collected from 38 UC patients, 20 of whom had undergone RPC and compared with the results in 18 healthy controls and in 12 familial adenomatous polyposis (FAP) patients who had undergone RPC. We were interested in evaluating if there was any correlation between B1a blood cell concentration and ESR and CRP levels, clinical, endoscopic and histological activity, perinuclear anti-neutrophil cytoplasmic antibody (pANCA) and extra-intestinal symptoms., Results: B1a cell blood concentration was reduced in non-operated UC patients (20.7 +/- 4.6/microl) with respect to that in healthy controls (71.1 +/- 18.0/microl, p < 0.05). It was also lower in UC patients with RPC (24.9 +/- 1.0/microl) compared to RPC for FAP (48.2 +/- 6.2, p < 0.05). B1a cell rate correlated inversely in UC patients with ESR (R = -0.41, p < 0.05) and CRP levels (R = -0.47, p = 0.01)., Conclusion: B1a cell concentration was reduced in the blood of patients with UC even after the diseased organ was surgically removed by proctocolectomy. As these cells play an important role in natural immunity against luminal stimuli, consistently lower levels that are found in UC patients could be responsible for the impaired immunologic response to gut antigens in this disease.

Surgical repair of an abdominal aortic aneurysm (AAA) concomitant with a horseshoe kidney (HSK) may be technically demanding because of the complex anomalies of the kidney and of its collecting system and arteries, the greater risk of HSK-related complications, and the often unexpected intraoperative finding of HSK itself. We reviewed a database of more than 500 patients with AAA observed in our surgical department from 1994 to the time of writing. Five patients had AAA concomitant with HSK. Two of these patients did not undergo surgery because of the small dimension of the aneurysm or because of their poor health. The other three underwent successful repair of AAA with different techniques; namely, an aortobifemoral bypass via a thoracoabdominal retroperitoneal incision in one, a straight graft via an emergency median laparotomy in one, and an endovascular repair followed by open surgery 4 years later for endotension in one. Abnormal minor renal arteries were deliberately occluded and only one of these caused a minor renal infarct, but without functional impairment. These data and a review of the literature indicate that HSK should not preclude repair of coexistent AAA, as imaging procedures provide the information necessary to plan the best approach for each patient. Up-to-date surgical procedures, a posteriori retroperitoneal approach or endovascular repair, and deliberate occlusion of the minor renal arteries appear feasible and safe as they avoid most of the anatomical problems and provide results equivalent to those of uncomplicated aortic surgery.