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Diet affects Inflammatory Bowel Disease (IBD) patients' quality of life. An adequate Food Literacy (FL) level enables adequate food choices. Currently, there is a lack of knowledge on the FL degree in patients with IBD. To deepen this item, we measured for the first time the degree of FL in IBD patients and then we analyzed its correlation with health and socio-demographic variables.This is an observational prospective study includingsubjects with IBD belonging to A.M.I.C.I. ONLUS association. We first measured the degree of FL through Literacy Survey (FLS-IT) questionnaire (containing the Newest Vital Sign (NVS)). In addition, we analyzed the relationship between FL individual level and health and sociodemographic variables, evaluating which of these aspects have a positive or negative correlation with FL level. In detail, continuous variables were analyzed by Mann Whitney test. Differences among proportions were assessed using the chi-square test. A Spearman's rank correlation analysis was performed to correlate the sociodemographic and health status variable with FL index and NVS. A stepwise linear regression analysis with backward selection was performed to identify possible predictor of good food literary skills in IBS patients.Overall, 450 IBD subjects completed the FLS-IT questionnaire. Among them, 69.78% (n = 314) showed an inadequate FL level. Concerning NVS test, 14.22% showed an insufficient ability to interpret food labels. In addition, higher FL level was associated to better subjective health conditions (r = 0.1513; p = 0.0013), less limitations in daily living activities (r = 0.1430; p = 0.0026), higher physical activity (r = 1200; p = 0.0110) and no alcohol consumption (p = 0.0020). Finally, higher NVS scores were shown by women (r = 0.1408; p = 0.0028) and by younger subjects (r = -0.1686; p = 0.0003).We showed that an inadequate level of FL, related to the worst health status and the presence of several limitations in daily life, is widespread among our Italian cohort of IBD patients, and health and social status influence the ability to make adequate food choices. For this reason, it is necessary to investigate the problem and identify effective intervention strategies that will improve the patient's nutritional awareness.

Inflammation is a physiological, beneficial, and auto-limiting response of the host to alarming stimuli. Conversely, a chronic systemic low-grade inflammation (CSLGI), known as a long-time persisting condition, causes damage to the organs and host tissues, representing a major risk for chronic diseases. Currently, a high global incidence of chronic inflammatory diseases is observed, often linked to the lifestyle-related changes that occurred in the last decade. The main lifestyle-related factors are proinflammatory diet, psychological stress, tobacco smoking, alcohol abuse, physical inactivity, and indoor living and working with its related consequences such as indoor pollution, artificial light exposure, and low vitamin D production. Recent scientific evidence found that gut microbiota (GM) has a main role in shaping the host’s health, particularly as CSLGI mediator. Based on the lastest discoveries regarding the remarkable GM activity, in this manuscript we focus on the elements of actual lifestyle that influence the composition and function of the intestinal microbial community in order to elicit the CSLGI and its correlated pathologies. In this scenario, we provide a broad review of the interplay between modern lifestyle, GM, and CSLGI with a special focus on the COVID symptoms and emerging long-COVID syndrome.

Purpose The Montreal classification for Crohn’s disease includes “age at diagnosis” as a parameter but few is reported about the age at surgery. The aim of this study is to evaluate the short- and long-term differences in the postoperative surgical outcome and disease behaviour, according to the age at the first surgery. Methods Patients consecutively operated for abdominal Crohn’s disease during the period 1986–2012 at our centre were systematically analysed according to their age at first surgery. In our retrospective cohort, the age at first surgery ranged from 13 to 83 years, and patients were arbitrarily divided into four groups: ≤ 19 (G1), 20–39 (G2), 40–59 (G3) and ≥ 60 (G4) years old. Results In total, 1051 patients were included with a median follow-up time of 232 months. The four groups exhibited statistically significant differences in age at diagnosis, smoke habit, time between diagnosis and surgery, disease location and behaviour, history of perianal fistula or abscess, severe malnutrition requiring total parental nutrition before surgery, type of surgery, total length of resected bowel, median duration of hospitalization, incidence of abdominal recurrences and number of surgical recurrences. G1 displays an inverse linear trend with time in the severity of clinical characteristics when compared to G4 groups. On the contrary, the incidence of short-term complications, types of abdominal recurrence and presence of concomitant perianal disease did not vary among groups. In addition, at multivariate analysis, the age at surgery and the disease location were the only independent risk factors for abdominal surgical recurrence. Conclusion Despite first surgery is extremely more frequent between 20 and 59 years, patients from G1 and G4 groups showed clinical differences and peculiarities when compared to the other age groups. The most indolent CD behaviour and occurrence of surgical recurrence was observed in patients having their first abdominal surgery in the elderly, while patients operated before the age of 19 experienced a more aggressive disease course.

BACKGROUND & AIMS Mediterranean diet may be beneficial for inflammatory bowel disease (IBD). The aim of this study was to evaluate the level of adherence to MD in Italian patients with IBD. METHODS Eighty consecutive outpatients with IBD, 62 with Crohn's Disease (CD) and 18 with Ulcerative Colitis (UC) were included in the study. Demographic and clinical data, previous and current medical history, nutritional status and Quality of Life (QoL) assessed with the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) were assessed. Adherence to MD was studied with the Medi-Lite questionnaire. RESULTS IBD patients reported a mean Medi-Lite score of 10.4 with no significant differences between CD and UC patients (p = 0.543). Among CD patients, adherence to MD was higher in patients with inactive disease (p

Introduction Intra-abdominal abscesses complicating Crohn’s disease (CD) present an additional challenge as their presence can contraindicate immunosuppressive treatment whilst emergency surgery is associated with high stoma rate and complications. Treatment options include a conservative approach, percutaneous drainage, and surgical intervention. The current multicentre study audited the short-term outcomes of patients who underwent preoperative radiological drainage of intra-abdominal abscesses up to 6 weeks prior to surgery for ileocolonic CD. Methods This is a retrospective, multicentre, observational study promoted by the Italian Society of Colorectal Surgery (SICCR), including all adults undergoing ileocolic resection for primary or recurrent CD from June 2018 to May 2019. The outcomes of patients who underwent radiological guided drainage prior to ileocolonic resection were compared to the patients who did not require preoperative drainage. 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. Results Amongst a group of 575 included patients who had an ileocolic resection for CD, there were 36 patients (6.2%) who underwent abscess drainage prior to surgery. Postoperative morbidity (44.4%) and anastomotic leak (11.1%) were significantly higher in the group of patients who underwent preoperative drainage. Conclusions Patients with Crohn’s disease who require preoperative radiological guided drainage of intra-abdominal abscesses are at increased risk of postoperative morbidity and septic complications following ileocaecal or re-do ileocolic resection.

Background & aims The effect of the COVID-19 infection on nutritional status is not well established. Worldwide epidemiological studies have begun to investigate the incidence of malnutrition during hospitalization for COVID-19. The prevalence of malnutrition during follow-up after COVID-19 infection has not been investigated yet. The primary objective of the present study was to estimate the prevalence of the risk of malnutrition in hospitalized adult patients with COVID-19, re-evaluating their nutritional status during follow-up after discharge. The secondary objective was to identify factors that may contribute to the onset of malnutrition during hospitalization and after discharge. Methods We enrolled 142 COVID-19 patients admitted to Careggi University Hospital. Nutritional parameters were measured at three different timepoints for each patient: upon admission to hospital, at discharge from hospital and 3 months after discharge during follow-up. The prevalence of both the nutritional risk and malnutrition was assessed. During the follow-up, the presence of nutritional impact symptoms (NIS) was also investigated. An analysis of the association between demographic and clinical features and nutritional status was conducted. Results The mean unintended weight loss during hospitalization was 7.6% (p 61 years old), a statistically significant correlation between age and weight loss was found (r = 0.288 p = 0.05). Patients admitted to an Intensive Care Unit (ICU) or Intermediate Care Unit (IMCU) had a greater unintended weight loss than patients who stayed in a standard care ward (5.46% vs 1.19%; p

Preoperative patient care optimisation appears to be crucial for obtaining good surgical outcomes. Enhanced Recovery After Surgery (ERAS) underlines the necessity to recognize and treat malnutrition perioperatively and to prehabilitate with interventions that can modulate the lean body mass before and after surgery. This procedure has been extensively reported in colorectal cancer patients but in Inflammatory Bowel Disease (IBD) it has not yet been clearly evaluated. The aim of this study was to implement the perioperative nutritional items in surgical Crohn's disease (CD) and ulcerative colitis (UC) patients electively operated in an ERAS setting, thus to clarify the impact of a long-lasting prehabilitation program in IBD.Consecutive adult patients (age ≥18) were included as soon as scheduled for elective surgery for CD or UC. The nutritional intervention included personalized dietary counseling and oral nutritional supplements when necessary. Data prospectively recorded in each phase were: FFM, FM, FFMI and phase angle detected with BIVA, weight, BMI, unintended weight loss, DASI, energy and nutritional intake, gastrointestinal symptoms and bowel functions. Nutritional risk was detected according to the NRS 2002 screening tool. The impact of early oral nutrition on postoperative recovery was analysed.A total of 61 IBD patients (45 CD and 16 UC) were included. Muscle wasting was present at baseline assessment in 28% of cases, significantly associated with the presence of ileostomy (p 0.011) and of a previous IBD surgery (p 0.011). During the preoperative phase, there was a significant improvement in weight, BMI, FFM (CD p = 0.035; UC p = 0.017), FFMI (CD ns; UC p = 0.011) and phase angle (CD p = 0.014; UC p = 0.027). During the intra-hospital phase, weight and FFM decreased due to the catabolic effect of surgery, but in the whole perioperative period, both CD and UC patients did not change significantly in terms of body composition. Patients with earlier resumption of oral feeding had a significantly shorter hospital stay and a faster recovery of bowel function with no significant relationship with early postoperative complications.Nutritional prehabilitation positively modulated the body composition of IBD patients scheduled for elective surgery and therefore could represent a beneficial strategy to attenuate the impact of the surgical stress response on lean tissue in an ERAS setting. This effect is even more evident in high nutritional risk patients. Early postoperative oral feeding seems feasible and well tolerated in IBD. This approach positively influences the restoration of bowel function and the duration of hospital stay.

The sporadic parathyroid pathology of surgical interest is primarily limited to lesions that are the cause of hormonal hyperfunction (primary hyperparathyroidism). In recent years, parathyroid surgery has evolved significantly, and numerous minimally invasive parathyroidectomy techniques have been developed. In this study, we describe a single-center and well-documented case series of sporadic primary hyperparathyroidism, surgically treated by a single operator in the Endocrine Surgery Unit of the Surgical Clinic of the University of Florence-Careggi University Hospital, recorded and updated in a dedicated database that embraces the entire evolutionary timeframe of parathyroid surgery. From January 2000 to May 2020, 504 patients with a clinical and instrumental diagnosis of hyperparathyroidism were included in the study. The patients were divided into two groups, based on the application of intraoperative parathyroid hormone (ioPTH). The analysis shows that the use of ioPTH with the rapid method could be ineffective in helping surgeons in primary operations, especially when ultrasound and scintiscan are concordant. The advantages obtained by not using intraoperative PTH are not only economic. In fact, our data shows shorter operating and general anesthesia times and hospital stays, having an important impact on patient biological commitment. Furthermore, the significant reduction in operating time makes it possible to almost triple the volume of activity in the same unit of time available, with an undeniable advantage for the reduction of waiting lists. In recent years, minimally invasive approaches have allowed surgeons to reach the best compromise between invasiveness and aesthetic results.

T lymphocytes accumulate in inflamed tissues of patients with chronic inflammatory diseases (CIDs) and express pro-inflammatory cytokines upon re-stimulation in vitro. Further, a significant genetic linkage to MHC genes suggests that T lymphocytes play an important role in the pathogenesis of CIDs including juvenile idiopathic arthritis (JIA). However, the functions of T lymphocytes in established disease remain elusive. Here we dissect the transcriptional and the clonal heterogeneity of synovial T lymphocytes in JIA patients by single-cell RNA sequencing combined with T cell receptor profiling on the same cells. We identify clonally expanded subpopulations of T lymphocytes expressing genes reflecting recent activation by antigen in situ. A PD-1+ TOX+ EOMES+ population of CD4+ T lymphocytes expressed immune regulatory genes and chemoattractant genes for myeloid cells. A PD-1+ TOX+ BHLHE40+ population of CD4+ , and a mirror population of CD8+ T lymphocytes expressed genes driving inflammation, and genes supporting B lymphocyte activation in situ. This analysis points out that multiple types of T lymphocytes have to be targeted for therapeutic regeneration of tolerance in arthritis.

Crohn’s disease (CD) patients are generally considered at high risk of post-operative complications with respect to non-CD patients. The primary endpoint of this study is to compare early major complications rates between CD and colon cancer (CC) patients undergoing mini-invasive ileo-colic resections or right hemicolectomies. The secondary endpoint is to evaluate the role of pre-operative medication with anti-TNF as a possible risk factor for post-operative complications. An observational retrospective study was carried on patients who underwent mini-invasive ileocolic resections for CD and right hemicolectomies for CC at Digestive Surgery Unit and IBD Unit, Careggi Univeristy Hospital, from January 1, 2008, to June 1, 2019. Data collected included demographic and clinical informations, pre-operative anti-TNF use, major complications and mortality. Hundred and thirty-three mini-invasive ileocolic resections for CD and 131 mini-invasive right hemicolectomies for CC were included. Early major post-operative complications rates were 4.5% for CD patients and 3% for CC patients (p = 0.535). Anastomotic leak rates were 1.5% in both groups. There was no significant difference in mean length of stay; while, mean operation time was significantly longer in CD patients (p

Several international guidelines recommend a peri-operative immunonutrition (IN) support for patients care in elective colorectal surgery, to reduce postoperative complications, particularly infections. In Crohn’s patients, is also used to mitigate the severity of the disease. We performed a pilot study on 16 Crohn’s patients undergoing intestinal surgery for active disease, not responsive to pharmacological treatment; half of them received an oral nutritional supplement enriched with immunonutrients (IN patients) for 7 days prior to surgery, in addition to normal food intake. Markers of oxidative stress (Advanced Glycated End-products (AGEs) and Advanced Oxidation Protein Products (AOPPs) were measured both in plasma and tissue samples wherein the Receptor for Advanced Glycation End products (RAGE) and Tight Junction Protein 1 (TJP1) gene expression were also determined. Plasma AGEs were significantly and positively correlated with tissue levels of AGEs (p = 0.0354) and AOPPs (p = 0.0043) while they were negatively correlated with TJP1 expression (p = 0.0159). The expression of RAGE was also negatively correlated with that of TJP1 gene (p = 0.0146). IN patients exhibited significantly lower AGEs plasma levels (p = 0.0321) and a higher mucosal TJP1 expression (p = 0.0182). No patient had postoperative complications and the length of hospital stay was similar in the two groups, but IN patients, showed a significantly shorter time to resume fluid and solid diet. These preliminary data suggest that IN might support patient’s recovery by improving intestinal mucosa barrier function through the regulation of AGEs/RAGE signaling.

Background: Accurate identification of malnutrition and preoperative nutritional care in Inflammatory Bowel Disease (IBD) surgery is mandatory. There is no validated nutritional screening tool for IBD patients. We developed a novel nutritional screening tool for IBD patients requiring surgery and compared it with other tools. Methods: we included 62 consecutive patients scheduled for elective surgery. The IBD Nutritional Screening tool (NS-IBD) was developed to screen patients for further comprehensive assessment. NRS-2002, MUST, MST, MIRT, SaskIBD-NR are compared with the new test. All screening tests were subsequently related to new GLIM criteria. Results: according to GLIM criteria, 25 (40%) IBD patients were malnourished (15 CD and 10 UC, 33% vs. 63%, p = 0.036). Stage 1 malnutrition was reported in ten patients, while stage 2 was detected in 15 patients. The comparison of each nutritional risk tool with GLIM criteria showed sensitivity of 0.52, 0.6, 0.6, 0.84, 0.84 and 0.92 for SASKIBD-NR, MUST, MST, NRS-2002, MIRT, and the new NS-IBD, respectively. Conclusions: in IBD, currently adopted nutritional screening tools are characterized by a low sensitivity when malnutrition diagnosis is performed with recent GLIM criteria. Our proposed tool to detect malnutrition performed the best in detecting patients that may require nutritional assessment and preoperative intervention.

BACKGROUND Crohn’s disease (CD) is a complex disorder resulting from the interaction of genetic, environmental, and microbial factors. The pathogenic process may potentially affect any segment of the gastrointestinal tract, but a selective location in the terminal ileum was reported in 50% of patients. AIM To characterize clinical sub-phenotypes (colonic and/or ileal) within the same disease, in order to identify new therapeutic targets. METHODS 14 consecutive patients undergoing surgery for ileal CD were recruited for this study. Peripheral blood samples from each patient were collected and the main polymorphisms of the gene Card15/Nod2 (R702W, G908R, and 1007fs) were analyzed in each sample. In addition, tissue samples were taken from both the tract affected by CD and from the apparently healthy and disease-free margins (internal controls). We used a multiplex gene assay in specimens obtained from patients with ileal localization of CD to evaluate the simultaneous expression of 24 genes involved in the pathogenesis of the disease. We also processed surgery gut samples with routine light microscopy (LM) and transmission electron microscopy (TEM) techniques to evaluate their structural and ultrastructural features. RESULTS We found a significant increase of Th17 (IL17A and IL17F, IL 23R and CCR6) and Th1 (IFN-γ) gene expression in inflamed mucosa compared to non-inflamed sites of 14 CD patients. DEFB4 and HAMP, two genes coding for antimicrobial peptides, were also strongly activated in inflamed ileal mucosa, suggesting the overwhelming stimulation of epithelial cells by commensal microbiota. IFN-γ and CCR6 were more expressed in inflamed mucosa of CD patients with ileal localization compared with patients with colonic localization suggesting a more aggressive inflammation process in this site. Morphological analysis of the epithelial lining of Lieberkün crypts disclosed enhanced release activity from goblet mucocytes, whereas the lamina propria contained numerous cells pertaining to various lines. CONCLUSION We observed that the expression of ileal genes related to Th1 and Th17 activity is strongly activated as well as the expression of genes involved in microbiota regulation.

Longitudinal research emphasizes that nonstandard (i.e., temporary contracts, part-time and multiple jobs) and discontinuous occupational trajectories (i.e., intermittent unemployment or inactivity) are associated with lower levels of mental health. A branch of this research highlights, over many years of observation the importance of the time of exposure to nonstandard occupational trajectories as a social determinant of health. However, the timing of the observed period and the multidimensionality of nonstandard occupational trajectories have been highly neglected. In this study, we analyze the Swiss Household Panel data, which used a life history calendar to collect occupational trajectories across the lifespan. The data included the trajectories of 5690 initially healthy Swiss residents and were used to reconstruct the occupational trajectories during the first 20 years in the world of work. A sequence analysis revealed eight distinct types of occupational careers based on three dimensions: type of contract, labor market status and number of simultaneous jobs. The results show that discontinuous occupational trajectories (characterized by continuous jumps between temporary work, long periods of unemployment, social help, inactivity or part-time work) are associated with higher depressive symptoms, lower life course mental health and lower self-reported health during an individual's first 20 years in the world of work.

Hepatocellular carcinoma (HCC) is the most prevalent primary malignancy in patients suffering from chronic liver diseases and cirrhosis. Recent attention has been paid to the involvement of the gut-liver axis (GLA) in HCC pathogenesis. This axis results from a bidirectional, anatomical and functional relationship between the gastrointestinal system and the liver. Moreover, the complex network of interactions between the intestinal microbiome and the liver plays a crucial role in modulation of the HCC-tumor microenvironment, contributing to the pathogenesis of HCC by exposing the liver to pathogen-associated molecular patterns, such as bacterial lipopolysaccharides, DNA, peptidoglycans and flagellin. Indeed, the alteration of gut microflora may disturb the intestinal barrier, bringing several toll-like receptor ligands to the liver thus activating the inflammatory response. This review explores the new therapeutic opportunities that may arise from novel insights into the mechanisms by which microbiota immunomodulation, represented by probiotics, and prebiotics, affects HCC through the GLA.

Patient: Male, 63-year-old Final Diagnosis: Erdheim-Chester disease Symptoms: Splenic rupture Medication: — Clinical Procedure: Splenectomy Specialty: Anatomy • Hematology • Pathology Objective: Rare disease Background: Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis characterized by foamy histiocytes, Touton-like giant cells, and fibrosis, typically affecting the diaphyseal and metaphyseal region of the long bones but that can involve any organ or tissue. ECD is usually associated with the BRAF V600E mutation or with other molecular mutations inserted in the MAPK cascade. Case Report: We present the case of a 63-year-old man with a previous history of myocardial infarction who underwent an emergency splenectomy for splenic rupture after an accidental fall. Histological examination of the spleen showed a diffuse xanthogranulomatous proliferation (CD68+, CD163+, S100–, CD1a–) with rare Touton-like giant cells in the red pulp. Based on the histologic findings, a diagnosis of ECD was made. However, skeletal involvement and BRAF V600E mutation were not detected. Conclusions: Cases of non-Langerhans cell histiocytosis that are histologically consistent with ECD in unusual sites have been increasingly described. There is also anecdotal evidence for cases being associated with mutations besides BRAF V600E or with no genetic alteration and no skeletal involvement. Likewise, the spectrum of clinical and molecular features of ECD can be broader than previously considered. Furthermore, there is evidence that various phases of the disease can show different clinical presentations with distinct prognostic impact, according to the mutational spectrum. Recognizing ECD at an early stage allows more effective patient management, and pathologists and clinicians should be aware of the unusual clinical presentations of this rare condition.

Introduction The technical complexity of D2 lymphadenectomy and esophago-jejunal anastomosis are the main factors that limit the application of laparoscopic surgery in the treatment of gastric cancer. Robotic assisted gastric surgery provides potential technical advantages over conventional laparoscopy but an improvement in clinical outcomes after robotic surgery has not been demonstrated yet. Evidence acquisition Data from 128 consecutive patients who had undergone robotic gastrectomy for gastric cancer at our center institution from April 2017 to June 2020 where retrospectively reviewed from a prospectively updated database. A narrative review was then carried out on PubMed, Embase and Scopus using the following keywords: "gastric cancer," "robotic surgery," "robotic gastrectomy" and "robotic gastric surgery". Evidence synthesis Ninety-eight patients underwent robotic distal gastrectomy and 30 underwent robotic total gastrectomy. The mean value of estimated blood loss was 99.5 ml. No patients required conversion to laparoscopy or open surgery. The median number of retrieved lymph nodes was 42. No tumor involvement of the proximal or distal margin was found in any patient. The median time to first flatus and first oral feeding was on postoperative day 3 and 5, respectively. We registered 6 leakages (4.6%), namely, 1 duodenal stump leakage and 5 anastomotic leakages. No 30-day surgical related mortality was recorded. The median length of hospital stay was 10.5 days (range 4-37). Conclusions Published data and our experience suggest that the robotic approach for gastric cancer is safe and feasible with potential advantages over conventional laparoscopy.

Background and AimsThe pathogenesis of Crohn’s disease [CD] is still unclear. Disorders in the mucosal immunoregulation and its crosstalk with the microbiota may represent an important component in tissue injury. We aimed to characterize the molecular immune response distribution within the ileal layers and to evaluate the correlated microbiota in pathological/healthy settings comparing first surgery/relapse clinical conditions.MethodsWe enrolled 12 CD patients. A comprehensive analysis of an ileal mucosa, submucosa and serosa broad-spectrum cytokine panel was performed through a multiplex approach. In addition, ileal microbiota composition was assessed through next generation sequencing.ResultsWe observed a distinct profile [of IL1-α, IL-1β, IL-4, IL-8, ICAM-1, E-Selectin, P-Selectin, IP-10, IL 6 and IL 18] across the CD vs healthy ileal layers; and a different distribution of IFN- γ, P-Selectin, IL-27 and IL-21 in first surgery vs relapse patients. In addition, the phylum Tenericutes, the family Ruminococcaceae, and the genera Mesoplasma and Mycoplasma were significantly enriched in the pathological setting. Significant microbiota differences were observed between relapse and first surgery patients regarding the class Bacteroidia, and the genera Prevotella, Flavobacterium, Tepidimonas and Escherichia/Shigella. Finally, the abundance of the genus Mycoplasma was positively correlated with IL-18.ConclusionsWe describe a dissimilarity of cytokine distribution and microbiota composition within CD and adjacent healthy ileal tissue layers and between first operation and surgical relapse. Our results give potential insight into the dynamics of the gut microbiota–immune axis in CD patients, leading to detection of new biomarkers.

Introduction Single-incision laparoscopic surgery (SILS) aims to minimize the surgical access trauma by reducing the number of abdominal incisions to a single site, potentially offering better cosmetic results and decreased postoperative pain. In this study, we compare the results of SILS ileocolic resection for Crohn’s disease (CD) to conventional laparoscopy and open surgery using a propensity score–matched analysis in a retrospective national multicentre study. Methods All consecutive patients undergoing elective SILS ileocaecal or redo ileocolic resection for primary and recurrent CD from 1 June 2018 to 31 May 2019 were included. Patients were matched 1:1:1 with laparoscopy and open surgery according to perianal disease, recurrent disease, penetrating phenotype of CD, history of previous abdominal surgery, preoperative medical treatment with steroids and anti-TNF. Postoperative morbidity within 30 days of surgery was the primary endpoint. Results Fifty-eight patients were included in each group, for a total of 174 patients. The conversion rate for SILS and laparoscopy was 10.3% and 12%, respectively, with no difference in the incidence of postoperative complications (13.8% and 12%, p = 0.77), whilst open surgery demonstrated a worse morbidity profile, with a complication rate of 25.9% (p < 0.0001). Median length of hospital stay following SILS ileocolic resection was 5 days, significantly shorter compared to 7 days for laparoscopy and 9 for open surgery (p < 0.0001). Conclusions SILS ileocolonic resection for CD demonstrated a comparable morbidity profile compared to laparoscopy in selected patients, with a reduced length of postoperative hospital stay.

Background. CARD15/NOD2 is the most significant genetic susceptibility in Crohn’s disease (CD) even though a relationship between the different polymorphisms and clinical phenotype has not been described yet. The study is aimed at analyzing, in a group of CD patients undergoing surgery, the relationship between CARD15/NOD2 polymorphisms and the clinical CD behavior after a long-term follow-up, in order to identify potential clinical biomarkers of prognosis. Methods. 191 surgical CD patients were prospectively characterized both for the main single nucleotide polymorphisms of CARD15/NOD2 and for many other environmental risk factors connected with the severe disease form. After a mean follow-up of 7.3 years, the correlations between clinical features and CD natural history were analyzed. Results. CARD15/NOD2 polymorphisms were significantly associated with younger age at diagnosis compared to wild type cases ( p < 0.05 ). Moreover, patients carrying a 3020insC polymorphism presented a larger Δ between diagnosis and surgery ( p = 0.0344 ). Patients carrying an hz881 and a 3020insC exhibited, respectively, a lower rate of responsiveness to azathioprine ( p = 0.012 ), but no difference was found in biologic therapy. Finally, the risk of surgical recurrence was significantly associated, respectively, to age at diagnosis, to familial CD history, to diagnostic delay, to arthritis, and to the presence of perioperative complications. Conclusions. 3020insC CARD15 polymorphism is associated with an earlier CD onset, and age at CD diagnosis < 27 years was confirmed to have a detrimental effect on its clinical course. In addition, the familiarity seems to be connected with a more aggressive postoperative course. Finally, for the first time, we have observed a lower rate of responsiveness to azathioprine in patients carrying an hz881 and a 3020insC.

Summary Background & aims Despite little evidence available to date, the dietary intake assessment is considered a useful tool to optimize dietary intervention for the improvement of the nutritional status of IBD patients. The primary aim was to compare the dietary intake of IBD patients scheduled for surgery with the dietary reference values (DRVs) for the Italian population (LARN) and the ESPEN guidelines for clinical nutrition in IBD. The secondary aim was to describe the dietary patterns of patients with CD and UC in relation to the disease-specific and nutritional parameters and to compare these results to a control group in order to evaluate if similar nutritional intakes than in oncologic patients are found in IBD. Methods Between January 2019 and March 2020, 62 consecutive IBD patients (46 CD and 16 UC) with age from 18 to 79 years scheduled for surgery were recruited. Patients received a comprehensive nutritional assessment, including food or nutrition-related history, anthropometric and body composition measurements. A group of 61 oncologic patients scheduled for colorectal cancer (CRC) surgery was used as control. Results IBD patients showed a higher caloric and nutritional intake than CRC group, despite a higher frequency of underweight, and a lower prevalence of overweight and obesity. IBD patients showed an inadequate intake of proteins, n-3 PUFA, fiber, iron, calcium, potassium, magnesium, zinc, vitamin D and vitamin B12 according to ESPEN guidelines for clinical nutrition in IBD and LARN. Oral intake was not influenced by gender, IBD subtype, longer duration of disease and previous surgery. In CD, fistulizing behaviour negatively influenced oral intake. Conclusions in IBD patients, the evaluation of macronutrients and micronutrients intake before surgery, can contribute to evaluate and to correct the onset of nutritional deficiencies. Specific dietary recommendations seem required, in order to integrate specific nutritional inadequacies. IBD patients referred to surgery have to be considered at high nutritional risk like oncologic patients are.

T lymphocytes accumulate in inflamed tissues of patients with chronic inflammatory diseases (CIDs) and express pro-inflammatory cytokines upon re-stimulation in vitro. Further, a significant genetic linkage to MHC genes suggests that T lymphocytes play an important role in the pathogenesis of CIDs including juvenile idiopathic arthritis (JIA). However, the functions of T lymphocytes in established disease remain elusive. Here we dissect the transcriptional and the clonal heterogeneity of synovial T lymphocytes in JIA patients by single-cell RNA sequencing combined with T cell receptor profiling on the same cells. We identify clonally expanded subpopulations of T lymphocytes expressing genes reflecting recent activation by antigen in situ. A PD-1

Introduction/AbstractT lymphocytes accumulate in inflamed tissues of patients with chronic inflammatory diseases (CIDs) and express pro-inflammatory cytokines upon re-stimulation in vitro1–29. Further, a significant genetic linkage to MHC genes suggests that T lymphocytes play an important role in the pathogenesis of CIDs including juvenile idiopathic arthritis (JIA)30–33. However, the functions of T lymphocytes in established disease remain elusive. Here we dissect the heterogeneity of synovial T lymphocytes in JIA patients by single cell RNA-sequencing. We identify subpopulations of T lymphocytes expressing genes reflecting recent activation by antigen in situ. A PD-1+TOX+EOMES+ population of CD4+ T lymphocytes expressed immune regulatory genes and chemoattractant genes for myeloid cells. A PD-1+TOX+BHLHE40+ population of CD4+, and a mirror population of CD8+ T lymphocytes expressed genes driving inflammation, and genes supporting B lymphocyte activation. This analysis points out that multiple types of T lymphocytes have to be targeted for therapeutic regeneration of tolerance in arthritis.

Background: The diagnosis of thyroid cancer is continuously increasing and consequently the amount of thyroidectomy. Notwithstanding the actual surgical skill, postoperative hypoparathyroidism still represents its most frequent complication. The aims of the present study are to analyze the rate of postoperative hypoparathyroidism after thyroidectomy, performed for cancer by a single first operator, without any technological aid, and to compare the data to those obtained adopting the most recent technological adjuncts developed to reduce the postoperative hypoparathyroidism. Methods: During the period 1997–2020 at the Endocrine Surgery Unit of the Department of Clinical and Experimental Medicine of the University of Florence, 1648 consecutive extracapsular thyroidectomies for cancer (401 with central compartment node dissection) were performed. The percentage of hypoparathyroidism, temporary or permanent, was recorded both in the first period (Group A) and in the second, most recent period (Group B). Total thyroidectomies were compared either with those with central compartment dissection and lobectomies. Minimally invasive procedures (MIT, MIVAT, some transoral) were also compared with conventional. Fisher’s exact and Chi-square tests were used for comparison of categorical variables. p &lt, 0.01 was considered statistically significant. Furthermore, a literature research from PubMed® has been performed, considering the most available tools to better identify parathyroid glands during thyroidectomy, in order to reduce the postoperative hypoparathyroidism. We grouped and analyzed them by technological affinity. Results: On the 1648 thyroidectomies enrolled for the study, the histotype was differentiated in 93.93 % of cases, medullary in 4% and poorly differentiated in the remaining 2.06%. Total extracapsular thyroidectomy and lobectomy were performed respectively in 95.45% and 4.55%. We recorded a total of 318 (19.29%) cases of hypocalcemia, with permanent hypoparathyroidism in 11 (0.66%). In regard to the literature, four categories of tools to facilitate the identification of the parathyroids were identified: (a) vital dye, (b) optical devices, (c) autofluorescence of parathyroids, and (d) autofluorescence enhanced by contrast media. Postoperative hypoparathyroidism had a variable range in the different groups. Conclusions: Our data confirm that the incidence of post-surgical hypoparathyroidism is extremely low in the high volume centers. Its potential reduction adopting technological adjuncts is difficult to estimate, and their cost, together with complexity of application, do not allow immediate routine use. The trend towards increasingly unilateral surgery in thyroid carcinoma, as confirmed by our results in case of lobectomy, is expected to really contribute to a further reduction of postsurgical hypoparathyroidism.

Summary Crohn's disease (CD) is a multifactorial immunologically mediated disease. In this study we explored, for the first time, the efficacy of the Multiplex Gene Assay technology for detecting mRNA expression profile of 24 selected CD related genes in endoscopic biopsies and surgical specimens from CD patients with colonic localization of the disease. The polymorphisms of genes most frequently associated with CD were also analysed in DNA samples from the same patients. The analysis of endoscopic samples showed increased expression of 7 genes in inflamed mucosa compared to non-inflamed mucosa and suggests the activation of the autophagy process and of a Th17 adaptive response. The analysis of surgical specimens showed increased expression of 16 genes in inflamed tissue compared to non-inflamed internal controls and revealed the activation of immune-adaptive Th17 response in association with a Th1 response. Furthermore, an increased expression of genes involved in ionic transport and signal transduction was found in inflamed mucosa compared to non-inflamed internal controls. This study confirms the activation of Th17 and Th1 adaptive-immune response also in colonic CD. It should be stressed that these responses have been disclosed in biopsy tissue, while only Th17 differentiation is revealed in endoscopic tissue. Interestingly, the polymorphisms analysis revealed that a homozygous genotype is associated to a more complicated clinical course.

Background Distal pancreatectomy is the most frequent operation for insulinomas complicating multiple endocrine neoplasia type 1 insulinoma, although there are conditions for which a different operative approach might be preferable. In this article, we report the operative experience of a referral center for multiple endocrine neoplasia type 1 insulinoma. Methods Twelve patients underwent operations between 1992 and 2015: 8 underwent a distal pancreatic resection, and 4 underwent a pancreatoduodenectomy. Enucleation of other macroadenomas present in the remnant pancreas was performed in 9 out of these 12 patients. Results Operative complications (2 pancreatic fistulas and 2 cases of pancreatitis) occurred in 4 of the 8 distal pancreatic resections. In 1 patient, reoperation was required to resolve the complications of the first operation. At pathologic analysis, multiple insulinomas were found in 5 patients, lymph-nodal metastasis positive for insulin in 2 patients, multiple nonfunctioning pancreatic tumors in all patients, glucagonoma in 4 patients, and gastrinoma in the duodenum or lymph nodes in 4 patients. All the patients were treated successfully for the hypoglycemic/hyperinsulinemic syndrome with no clinical recurrence at a mean follow-up of 85 months (range 4–242 months). Recurrent nonfunctioning pancreatic tumor macroadenomas in the remnant pancreas occurred in only 1 of the 12 patients, and no progression of the gastrinomas was observed. None of the patients developed diabetes mellitus. Conclusion Resection of the most severely affected part of the pancreas, whether left or right, associated with enucleation of concomitant macroadenomas in the preserved pancreas is recommended for the treatment of hypoglycemic/hyperinsulinemic syndrome and to prevent malignant progression of nonfunctioning pancreatic tumors in patients with multiple endocrine neoplasia type 1. If the head of the pancreas is the most affected site and the Zollinger-Ellison syndrome is concomitant, then pancreatoduodenectomy should be preferred over distal pancreatectomy.

Introduction: No previous study clearly focuses on laparoscopic technique to perform the second stage surgery (proctectomy with ileal pouch-anal anastomosis [IPAA]) after total colectomy for acute/severe ulcerative colitis (UC). We describe the procedural steps for a simple and rational minimally invasive second stage surgery, reporting intra- and short-term post-operative results. Patients and Methods: During the period December 2014–December 2015, 10 consecutive patients (8 males and 2 females) with mean age of 48 years underwent laparoscopic proctectomy and IPAA adopting our novel approach. They were operated 3 months after the previous total colectomy which has been performed, respectively, for acute (three patients) or severe (seven patients) UC. Intraoperative data and post-operative complications, divided as minor and major, were recorded and analysed. A body image questionnaire was administered to all patients to evaluate the cosmetic results of the procedure. Results: Overall mean surgical time was 235 ± 49 min. During the post-operative course, three patients required morphine for >48 h, no patient needed blood transfusion and bowel movements recovery happened as mean during the 2nd day. No early major complications happened. Two patients (20%) developed peri-ileostomic wound infection at the right flank. Only one patient (10%) suffered from ileal-anal anastomotic dehiscence, conservatively treated till resolution. The average length of hospital stay was 8 ± 2 days. The body image questionnaire showed in all patients an extreme satisfaction about the results obtained (mean value = 59/64 points). Conclusions: Through three standardised surgical steps easily reproducible, we describe an almost scar-less procedure able to optimise the intraoperative time with good post-operative results in terms of complications and cosmesis.

Background In inflammatory bowel disease (IBD), malnutrition has been associated with increased postoperative complications incidence, longer hospital stay and higher costs. ESPEN guidelines recommend that all IBD patients must be screened for malnutrition. Recently, so-called GLIM criteria were developed to uniform malnutrition diagnosis. Our aim was to determine the prevalence of malnutrition comparing the different malnutrition criteria. Methods The nutritional status of all IBD patients’ candidates to surgery in our Centre during 2019 was assessed. According to the GLIM criteria, the diagnosis of malnutrition is based on the presence of almost one phenotypic criteria (non-volitional weight loss, low body mass index and reduced muscle mass) and almost one aetiologic criteria (reduced food intake or assimilation; biochemical inflammation). The results were compared with that found adopting ESPEN 2015 criteria for malnutrition to evaluate their concordance. Results Fifty-three consecutive IBD patients [38 Crohn’s disease (CD) and 15 ulcerative colitis (UC)] were evaluated. The average values of Body Mass Index, Free Fat Mass Index ad Phase Angle were 22.69 kg/m2, 17.6 kg/m2 and 5.8° respectively. According to the Nutritional Risk Screening (NRS) test 40% (21 patients) of patients were at high nutritional risk. Forty-five per cent (24 patients) were malnourished according to GLIM criteria (14 with severe malnutrition and 10 with moderate malnutrition), while according to the ESPEN criteria only 26% (14 patients) (Table 1). The correlation between GLIM and ESPEN, calculated with the Cohen’s kappa coefficient (k) was moderate/good (k 0,605). Conclusion GLIM criteria indicate higher prevalence of malnutrition than ESPEN criteria. Interestingly, the same 14 patients malnourished for ESPEN have severe malnutrition (Stage 2) according to GLIM. Furthermore, seven malnourished patients according to GLIM criteria are not considered at nutritional risk according to NRS, probably because it does not consider the muscle mass loss. Patients with CD have a higher prevalence of aetiological factors, while UC patients have a higher prevalence of phenotypic factors. Malnutrition prevalence was higher in UC probably due to the ileostomy present before second-stage surgery 4 months after subtotal colectomy in acute severe cases. The concordance between GLIM and ESPEN 2015 appears moderate/good.