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Le neoplasie colorettali comprendono sia le forme benigne, rappresentate nella maggior parte dei casi dagli adenomi e quelle maligne , in particolare dal cancro colorettale (CRC). Il cancro colorettale rappresenta una delle maggiori cause di cancro al mondo e, malgrado la riduzione dei tassi di incidenza nei paesi industrializzati dovuta all’implemento degli screening, il rapido cambiamento degli stili di vita in paesi in via di sviluppo sta determinando un aumento in popolazioni che storicamente erano meno suscettibili a questa patologia. Il cancro è di solito preceduto da lesioni premaligne la cui asportazione di fatto riduce il rischio di progressione maligna. I fattori di rischio per lo sviluppo del cancro colorettale sono l’età, l’obesità, la familiarità per cancro colorettale e le sindromi ereditarie con alta suscettibilità al cancro. Questo capitolo tratterà i tumori benigni e maligni del colon, le sindromi ereditarie ad alta suscettibilità di cancro colorettale oltre alle neoplasie dell’intestino tenue, con attenzione anche agli aspetti anatomo-patologici e chirurgici.

Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in Western countries. Although the aberrant expression of several microRNAs (oncomiRs) is associated with CRC progression, the molecular mechanisms of this phenomenon are still under investigation. Here we show that miR-101 expression is differentially impaired in CRC specimens, depending on tumour grade. miR-101 re-expression suppresses cell growth in 3D, hypoxic survival and invasive potential in CRC cells showing low levels of miR-101. Additionally, we provide molecular evidence of a bidirectional regulatory mechanism between miR-101 expression and important CRC pro-malignant features, such as inflammation, activation of the Wnt/β-catenin signalling pathway and epithelial–mesenchymal transition (EMT). We then propose that up-regulated miR-101 may function as a tumour suppressor in CRC and that its pharmacological restoration might hamper the aggressive ehaviour of CRC in vivo. MiR-101 expression may also represent a cancer biomarker for CRC diagnosis and prognosis.

POUCHITIS IS THE MOST COMMON COMPLICATIONS OF IPAA IN PATIENTS WITH UC. THE DIAGNOSIS OF POUCHITIS REQUIRED THE PRESENCE OF SYMPTOMS TOGETHER WITH CHARACTERISTIC ENDOSCOPIC AND HISTOLOGICAL ABNORMALITIES. ANTIBIOTIC THERAPY REPRESENTS THE MOST COMMON APPROACH.

SURGICAL AND MEDICAL COMBINED THERAPY FOR THE TREATMENT OF PERIANAL CROHN'S DISEASE. IMPACT OF BIOLOGICAL DRUGS ON HEALING OF PERIANAL FISTULAS. DESCRIPTION AND RESULTS OF INFLIXIMAB AND ADALIMUMAB LOCAL INJECTIONS AFTER SURGICAL DRAINAGES.

ROLE OF BIOLOGICAL DRUGS IN THE TREATMENT OF UC. IMPACT OF BIOLOGICAL DRUGS ON POSTOPERATIVE OUTCOME ACCORDING TO EARLY POSTOPERATIVE COMPLICATIONS IN PATIENTS SUBMITTED TO A 2 OR 3 STAGES RESTORATIVE PROCTOCOLECTOMY

INTRODUCTION: Adalimumab is effective in inducing and maintaining remission in active steroid-dependent Crohn's disease (CD). A post hoc analysis has also shown its effectiveness in perianal CD. AIMS & METHODS: The aim of this study was to evaluate the effectiveness of Adalimumab in the treatment of active perianal CD. Materials and methods: From January 2008 to May 2009, 64 consecutive patients, in a single tertiary center were prospectively followed (28f/36m, mean age 32 years, range 16-52, 8 smokers). The patients presented complex (trans or suprasphinteric, horse-shoes, multiple with or without rectal involvment) perianal fistulising disease, intolerant or resistant to immunosuppressive or secondary failure to infliximab (IFX). Treatment: After a deep surgical perineum sanitization, all patients received 160/80mg as induction dose followed by 40mg eow if responders. In case of loss of response, a weekly treatment was performed. Immunosuppressive therapy was suspended at the start of treatment, steroid dose was reduced of 2.5 mg/week after the induction phase.Definitions: remission= complete closure of the fistula assessed with Evaluation Under Anesthesia; Response= lack of drainage of purulent material at surgical evaluation. RESULTS: Results: Patients population: n = 64, 28 naive, 36 IFX failure, 42/64 colonic disease, 22/64 rectal involvement, 38/64 (59%) treated with azathioprine, 4/64 (6.2%) with methotrexate , 22/64 (34%) with steroids; media CDAI at baseline 310 (range 49-596), median IBDQat baseline 120 (range 58-208)]. At week 8, 8/64 patients (12,5%) were in remission and 20/64 (31%) responded; at week 24, 14/64 patients (22%) were in remission and 30/64 (47%) had a clinical response; at week 52, 32/52 patients (62%) were in remission and 38/52 (73%) had a clinical response; at week 76, 36/46 patients (78%) were in remission and 40/46 (87%) had a clinical response, assessed surgically. The effect was independent of the past use of IFX. Three patients loss response and moved to a temporary loop-ileostomy; 14/64 (22%) moved to a weekly treatment. No serious adverse events were registered. CONCLUSION: The data obtained in everyday clinical practice confirm the effectiveness of adalimumab in the treatment of perianal CD and the safety and stability of efficacy over time

Nuovi trattamenti della malattia paranale di Crohn. Terapia integrata fra chirurgia e nuove terapie biologiche

INDICAZIONI ALL'INTERVENTO E TIMING NEI PAZIENTI AFFETI DA RETTOCOLITE ULCEROSA. CHIRURGIA IN URGENZA ED ELEZIONE COMPLICANZE IMMEDIATE E A DISTANZA

INQUADRAMENTO DELLA MALATTIA PARANALE DI CROHN. DIAGNOSI CLINICA E STRUMENTALE, TRATTAMENTO CHIRURGICO TRADIZIONALE. NUOVI TRATTAMENTI INTEGRATI MEDICO-CHIRURGICI

Valutazione e trattamento delle principali complicanze precoci e tardive in pazienti sottoposti a proctocolectomia totale con ileoanoanastomosi

INTRODUCTION: BIologic therapy is effective in inducing and maintaining remission in active steroid-dependent Crohn's disease (CD). A post hoc analysis has also shown its effectiveness in perianal CD. AIMS & METHODS: The aim of this study was to evaluate the effectiveness of combined surgical and biological therapy in the treatment of active perianal CD. Materials and methods: From January 2008 to May 2009, 64 consecutive patients, in a single tertiary center were prospectively followed (28f/36m, mean age 32 years, range 16-52, 8 smokers). The patients presented complex (trans or suprasphinteric, horse-shoes, multiple with or without rectal involvment) perianal fistulising disease, intolerant or resistant to immunosuppressive. Treatment: After a deep surgical perineum sanitization, all patients received biological systemic or local therapy. Immunosuppressive therapy was suspended at the start of treatment, steroid dose was reduced of 2.5 mg/week after the induction phase.Definitions: remission= complete closure of the fistula assessed with Evaluation Under Anesthesia; Response= lack of drainage of purulent material at surgical evaluation. RESULTS: Results: Patients population: n = 64, 28 naive, 36 IFX failure, 42/64 colonic disease, 22/64 rectal involvement, 38/64 (59%) treated with azathioprine, 4/64 (6.2%) with methotrexate , 22/64 (34%) with steroids; media CDAI at baseline 310 (range 49-596), median IBDQat baseline 120 (range 58-208)]. At week 8, 8/64 patients (12,5%) were in remission and 20/64 (31%) responded; at week 24, 14/64 patients (22%) were in remission and 30/64 (47%) had a clinical response; at week 52, 32/52 patients (62%) were in remission and 38/52 (73%) had a clinical response; at week 76, 36/46 patients (78%) were in remission and 40/46 (87%) had a clinical response, assessed surgically. The effect was independent of the past use of IFX. Three patients loss response and moved to a temporary loop-ileostomy; 14/64 (22%) moved to a weekly treatment. No serious adverse events were registered. CONCLUSION: The data obtained in everyday clinical practice confirm the effectiveness of combined surgical and biological therapy in the treatment of perianal CD and the safety and stability of efficacy over time

Background: Chronic refractory pouchitis (CRP) is a long-term complication after ileal-pouch-anal-anastomosis (IPAA) and it my be associated with ileal inflammation. Aim: to determinate the efficacy of infliximab in treatment of CRP complicated by ileitis, using a wireless capsule endoscopy (WCE). Methods: 16 patients with CRP complicated by ileitis were enrolled. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. Ileitis was documented using WCE. Duodenum-jejunum and proximal-middle ileum were evaluated and the presence of small lesions and large lesions were noted. Crohn’s disease, intestinal infections were excluded in all patients. Patients are treated with infliximab and clinical response was recorded. WCE was repeated at week 10 and PDAI score was determined. Results: 10 patients were enrolled and completed the study. Clinical remission was achieved in 9 patients. At WCE and pouch endoscopy a complete recovery of lesions was observed in 8 patients. One patient presented 4 small lesions of the ileum at the 6-week of treatment and 1 patient did not show any modification. Clinical and endoscopic remission was maintained in these 8 patients at least 6 months. Conclusions: these preliminary results indicate that infliximab may be recommended for the treatment of CRP complicated by ileitis.

INQUADRAMENTO DELLE MALATTIE INFIAMMATORIE CRONICHE INTESTINALI: PRESENTAZIONE CLINICA E FISIOPATOLOGIA, DIAGNOSI, TERAPIA MEDICA E CHIRURGICA, CASI CLINICI

We appreciate the comments of Dr. Bell et al.1 about the results of our study.2 Their findings are different from ours in terms of the presence or absence of pouchitis: half of their patients with pre-pouch ileitis had no pouchitis and most of them were asymptomatic,3 while all our patients with lesions in the ileum had a chronic refractory pouchitis. We investigated our patients to exclude a possible infectious aetiology without any positive results, indeed microbiological studies did not reveal significant differences in the pouch flora compared to controls. However, we found that 45.7% of patients with chronic refractory pouchitis had a positive association with allele TLR9-1237C and CD 14-260T.4 These data suggest that the alleles TLR9-1237C and CD14-260T enhance synergistically the risk of developing chronic relapsing pouchitis. We agree with Bell et al. about the need for routine evaluation of the ileum in all patients with ileal pouch-anal anastomosis. We have started to study the small bowel with wireless capsule endoscopy before colectomy, and after ileal pouch-anal anastomosis but before ileostomy closure.

Background Pouchitis is a common long-term complication after ileal pouch anal anastomosis for ulcerative colitis. Chronic refractory pouchitis is a treatment-resistant condition that affects 5–15% of patients. AimTo test the hypothesis of a small bowel involvement using wireless capsule endoscopy. Material and methods This is a single-blind, prospective, cohort study. Twenty-four patients: 16 were patients with chronic refractory pouchitis and eight, with a macroscopically and histologically normal ileal pouch, were considered as control subjects. Diagnosis of pouchitis was confirmed using the pouchitis disease activity index. All subjects were submitted to wireless capsule endoscopy procedure. Within 2 weeks before wireless capsule endoscopy, patients underwent a pouch endoscopy and a small bowel follow-through. Re-examination of the colonic surgical and histological specimens was also performed. Results One patient with chronic pouchitis was excluded because of incomplete bowel cleaning. At small bowel follow-through of 16 patients, two subjects (13%) showed only a focal ectasia of the middle ileum and a substenosis of the pouch. At wireless capsule endoscopy all the 15 evaluable patients with chronic pouchitis (100%) showed diffuse lesions from duodenum to ileum consisting of aphthae, erosions, erythema, atrophy, cobblestone, deep ⁄ fissural ulcers. Conclusions This enteropathy needs further research, and wireless capsule endoscopy could be useful to show involvement of small bowel in patients with chronic pouchitis.

Valutazione dell'efficacia del promogram nella chiusura delle fistole paranali per malattia di Crohn

EVOLUZIONE TECNICA NEL TRATTAMENTO DELLE MALATTIE INFIAMMATORIE CRONICHE INTESTINALI. INDICAZIONI CHIRURGICHE E TRATTEMENTO RESETTIVO VS CONSERVATIVO NELLA MALATTIA DI CROHN. TERAPIA CHIRURGICA DELLA RETTOCOLITE ULCEROSA: INDICAZIONI, TECNICA CHIRURGICE E RISULTATI A DISTANZA DELL'INTERVENTO DI ILEOANOANASTOMOSI

VALUTAZIONE DELL'INCIDENZA E DEL RISCHIO DI COMPLICANZE PRECOCI E TARDIVE IN PAZIENTE SOTTOPOSTI A PROCTOCOLECTOMIA TOTALE CON ILEOANOANASTOMOSI. TRATTAMENTI CONSERVATIVI E CHIRURGICI DELLE PRINCIPALI COMPLICANZE

ANALISI DEI RISULTATI FUNZIONALI E DELLE COMPLICANZE A DISTANZA NEI PAZIENTI SOTTOPOSTI A PROCTOCOLECTOMIA TOTALE ED ILEOANOANASTOMOSI PER RETTOCOLITE ULCEROSA