Volume 84 - 2021 - Fasc.2 - Original articles
Post-operative pain after laparoscopic right hemicolectomy for Crohn’s disease: a case control study
Aim : Surgery for Crohn’s disease (CD) is characterized by
an enhanced inflammatory response. While inflammation can
induce hyperalgesia, post-operative pain following surgery for CD
has not been characterized. This retrospective study compared
a consecutive series of patients undergoing laparoscopic right
hemicolectomy for CD and neoplasia performed by a single
Method : Elective resections performed between Jan-2016
and Aug-2017 managed in an enhanced recovery pathway were
eligible for inclusion. Patients were excluded if open surgery was
performed, an ileostomy was fashioned, no patient-controlled
analgesia (PCA) was used or data were incomplete.
Results : 38 cases were included, 20 for neoplasia and 18
for ileocolonic CD. There was no difference in patient gender
(P=0.520). CD patients were younger (39.8±2.8 Vs 77.2±2.1 years,
P<0.001) but had an equivalent length of resection (312.9±43.5 Vs
283.3±71.7 mm, P=0.915). CD patients had higher pain scores on
post-operative day 1 (6.8±0.8 Vs 2.6±1.0, P<0.001), day 2 (5.0±0.5
Vs 1.6±0.9, P<0.001) and day 3 (4.1±0.6 Vs 1.3±0.7, P=0.008).
CD patients used their PCA for longer (85.7±16.3 Vs 47.7±4.2
hours, P=0.017) and used a greater total amount of morphine
(148.6±33.8 Vs 37.0±7.8 mg, P<0.001). Post-operative CRP was
higher in patients with CD on day 1 (P=0.011), day 2 (P=0.001), day
3 (P=0.001) and day 4 (P=0.007), but no leak or intra-abdominal
abscess occurred in either group.
Conclusions : CD patients experience increased post-operative
pain, require more post-operative analgesia and have an enhanced
post-operative inflammatory response. Further studies to elucidate
the mechanism of this hyperalgesia and strategies to obviate it are
Therapeutic outcome of diverticular associated colitis – a retrospective single centre experience
Background : Diverticular associated colitis (DAC) has become
increasingly appreciated as a form of inflammatory disease,
localized mainly in the sigmoid, and defined as chronic inflammation
of the interdiverticular mucosa with sparing of rectum, right colon
and diverticula themselves.
Methods : A retrospective case identification from January
2005 to December 2016 was performed. Patients with a diagnosis
of DAC based on clinical, endoscopic and histological findings
were enrolled. We analyzed their characteristics and response to
therapy, and performed a review of literature.
Results : Out of 377 pathology reports, 37 cases of DAC were
identified, with a median age of 73 years and followed during
1-13 years. Six patients (16.22%) were refractory to conservative
treatment and required surgery. In three patients (8.11%)
evolution to ulcerative colitis (UC) was observed. Patients were
divided into four endoscopic patterns, with a more benign course
for type A “crescentic fold disease” compared to the other subtypes.
Patients with type B “mild to moderate ulcerative colitis-like” were
at significantly higher risk of persistent disease activity or relapse
(p < 0.01).
Conclusion : DAC is a multifaceted disease and considered to be
a relatively benign condition. However, a subset of patients requires
surgery and/or may progress to develop UC.
Predictive factors of complications and 30-day mortality in patients undergoing percutaneous endoscopic gastrostomy: the utility of C-reactive protein to albumin ratio
Background and study aims : Percutaneous endoscopic gastrostomy (PEG) is a procedure that provides long term enteral nutrition.
To investigate the predictors of PEG-related complications and
30-day mortality rates and evaluate the indicators for deciding
whether to recommend elective PEG insertions, we sought to
determine the complications and early mortality rates of patients
who underwent PEG.
Patients and methods : We performed a retrospective analysis
of consecutive adult patients who had undergone PEG for the first
time between October 2016 and January 2019. The predictors of
complications and 30-day mortality were analyzed with receiver
operating characteristic (ROC) and logistic regression analysis.
Results : This study included 309 patients. Patients were
excluded from the study if they were < 18 years of age or there
were missing data about them. Out of 253 patients, 33 (13%) had
complications and 32 (12.6%) died within one month after PEG
insertion. A higher C-reactive protein (CRP) to albumin ratio was
the only independent factor predicting the complications (odds
ratio (OR) : 3.17 ; 95% CI : 1.26-8.00 ; p = 0.014). The independent
predictive factors for 30-day mortality after PEG placement
included higher urea levels and higher CRP to albumin ratios (OR :
3.78 ; 95% CI : 1.41-10.17 ; p = 0.008) (OR : 6.67 ; 95% CI : 1.87-
23.75 ; p = 0.003). The only predictor for both complications and
30-day mortality was the CRP to albumin ratio.
Conclusions : When appropriate, the PEG procedure can
provide a safe and effective method for enteral feeding. The CRP
to albumin ratio can be used to predict complications and early
mortality after PEG insertion. Because PEG is elective, higher CRP
to albumin ratios can be helpful in deciding to select patients for the
Recurrence rate of intramucosal gastric cancer with positive vertical margin due to lesion damage during endoscopic submucosal dissection
Background and study aim : In principle, additional surgery is
performed after endoscopic submucosal dissection for early gastric
cancer if the vertical margin is positive, regardless of lesion damage.
The recurrence rate of vertical margin-positive lesions due to
lesion damage after endoscopic submucosal dissection is unknown,
and unnecessary surgeries may be performed. In this study, we
investigated whether there was a difference in the recurrence rate
between vertical margin-positive lesions due to lesion damage and
vertical margin-negative lesions.
Patients and methods : We included 1,294 intramucosal gastric
cancer lesions that were resected by endoscopic submucosal
dissection between January 2008 and December 2016, without
additional surgery. The lesions were divided into the Damage and
No damage groups based on vertical margin status. The Damage
group had only one non-curative indication: a positive vertical
margin due to lesion damage. The No damage group had no noncurative indications. We compared the recurrence rate between the
Damage and No damage groups.
Results : The recurrence rates of the Damage and No damage
groups were 0% (0/23; 95% confidence interval: 0-14.8%) and 0%
(0/1,271; 95% confidence interval: 0-0.003%), respectively, with no
statistically significant difference.
Conclusions : In intramucosal gastric cancer, the recurrence
rate of vertical margin-positive lesions due to lesion damage was
0%, which did not differ from that of vertical margin-negative
lesions with curative resection. Follow-up, instead of additional
surgery, may be an option for patients with non-curative resection
when the only non-curative indication is a positive vertical margin
due to lesion damage.
Prospective switch study comparing two irrigation systems for transanal irrigation in children
Background and study aims : Transanal irrigation (TAI) is used
in children to treat constipation and incontinence. Belgium has 2
systems available: Colotip® (cheaper, however not designed for
TAI) or Peristeen®.
Patients and methods : This patient-control switch study is
the first to compare 2 TAI systems. Children regularly using
Colotip® for TAI were asked to participate, after consent, a visual
analogue scale (VAS) rating the system and a 2-week diary (fecal
continence, self-reliance, time spent on the toilet, pain, Bristol stool
scale, irrigation volume and frequency of enema) were completed.
Non-parametric statistics were used.
Results : Out of 26 children using Colotip®, 18 (69%) children
participated and 5 refused (fear n=1, satisfaction Colotip® system
n=7). Of these 18 children (interquartile range: 3-18 years, median
12.5 years, 9 girls) 5 patients stopped Peristeen® (pain n=1, fear
n=1 and balloon loss n=3) and 2 were lost from follow up. Dropouts
and included patients showed no statistical difference. In the 11
remaining patients, pseudo-continence (p 0.015), independence
(p 0.01) and VAS score (p 0.007) were significantly better with
Peristeen®, no difference was found in time spent on the toilet
(p 0.288) and presence of pain (p 0.785).
Conclusions : In children Peristeen® offered significantly
higher pseudo-continence and independency. 30% refused
participation because of satisfaction with the Colotip® and 30%
spina bifida patients reported rectal balloon loss due to sphincter
hypotony. To diminish Peristeen® failure, a test-catheter could be
of value. Considering Colotip® satisfaction, both systems should be
available. Patient selection for Peristeen® needs further research.
Reference values for the water load test in healthy school children and adolescents
Background and study aim : The water load test (WLT) is an
easy and cheap tool, useful in evaluating gastric accommodation
and visceral hypersensitivity. This test can be used in diagnosing
functional gastrointestinal disorders, like functional dyspepsia.
Our main aim was to propose reference values for the WLT. Our
secondary aim was to correlate the water volume drunk with the
students’ gender, age, and anthropometric measures.
Patients and methods : We performed the WLT in students aged
8 to 17 years. Students drank water ad libitum for 3 minutes or until
pain, satiety or vomiting occurred. We correlated anthropometric
variables with water volumes drunk. Upper and lower limit for the
maximum tolerated volume were calculated as the 5th and 95th
percentile. Pain and nausea were recorded before and after the test.
Results : We evaluated 99 students, with a median age (interquartile range) of 11 years 10-13 years) and 55.6 % were girls.
Median water volume drank was 380 ml (190-540 ml). Boys (523
ml, interquartile range : 275-760 ml) drank more water than girls
(380 ml, interquartile range : 190-570 ml) (p = 0.016). There was a
significant correlation between water volume drank and students´
age, weight, height, and body mass index. Of the students that
completed the WLT, 22.2 % had nausea and 30.3 % had mild
abdominal pain after the test.
Conclusions : We proposed reference values for the WLT in
children aged 8 to 17 years. Adverse effects are minimal, it is safe
to perform, and well tolerated.
Seronegative autoimmune hepatitis in children: a single-center experience
Background : Seronegative autoimmune hepatitis (AIH) is a
diagnostic challenge with unclear prognosis. This study describes
the features and outcomes of seronegative AIH in children.
Patients and methods : Patients under 18 years of age, who had
been diagnosed with AIH between April 2014 and April 2020, were
retrospectively evaluated. Seronegative AIH was identified by the
absence of the three conventional non-organ-specific autoantibodies
(anti-nuclear antibody [ANA], anti-smooth muscle antibody
[ASMA], and anti-liver kidney microsomal [anti-LKM] type 1
antibody), alongside the characteristic AIH liver histopathology
and a positive response to immunosuppressive therapy in the
absence of other liver diseases.
Results : The study included 54 patients with AIH. 15 (27.77%)
were seronegative at the time of diagnosis. 13 of the 15 seronegative
patients presented with acute hepatitis or acute liver failure (ALF).
Mean follow-up duration was 27.48 months in seronegative patients.
Two seronegative patients had lymphocytopenia on admission, and,
although the liver disease improved after corticosteroid treatment,
they developed aplastic anemia (AA). Other seronegative patients
responded well to immunosuppressive therapy.
Conclusions : Patients with seronegative AIH present frequently
with acute hepatitis or ALF. AIH diagnosis can be confirmed by
observing the effects of corticosteroid therapy in seronegative
patients with characteristic AIH liver histopathological features.
However, the presence of lymphocytopenia in seronegative patients
is a sign of bone marrow failure.
Hypoxic hepatitis with marked elevation of serum ferritin probably due to activation of intrahepatic macrophages: another form of hypoxic hepatitis hitherto not reported?
Background and study aims : Hypoxic hepatitis (HH) is an acute
liver injury that develops in patients with underlying diseases,
such as heart failure, respiratory failure, septic/toxic shock.
However, some patients do not have underlying diseases or episodes
which are known to result in HH. Here, we analyzed the clinical
characteristics of this particular patient group (called ‘unknown
HH’ hereafter) to understand its pathogenesis.
Patients and methods : Between October 2010 and January 2016,
157 consecutive patients with acute liver injury were admitted to
our hospital. Among these patients, 15 patients were categorized as
unknown HH. Medical histories and blood test results of unknown
HH were analyzed.
Results : Among 15 patients of unknown HH, 11 were habitual
drinkers and all experienced one of digestive symptoms which might
result in mild hypovolemia such as vomiting, diarrhea, appetite loss,
and epigastralgia. All patients of unknown HH presented marked
elevation of serum ferritin concentration paralleled with aspartate
transaminase (AST), alanine transaminase (ALT), and lactate
dehydrogenase (LDH) concentrations. The serum levels of ferritin,
ALT, LDH, and prothrombin time-international normalized ratio
(PT-INR) were rapidly decreased during hospitalization and all 15
patients of unknown HH recovered without any complication.
Conclusions : We found the particular group of HH with
marked elevation of serum ferritin probably due to intrahepatic
macrophage activation. Anti-inflammatory treatments might be
effective for this group of hypoxic hepatitis.
Can we use endocan level to determine severity of pancreatitis?
Background and study aims : Endothelial cell specific molecule-1
(ESM-1), also known as endocan, is a soluble proteoglycan secreted
by human vascular endothelial cells. In some studies, it has been
found that endocan have important effects on cell adhesion,
inflammation and angiogenesis. In this study, we aimed to evaluate
the endocan level in patients with pancreatitis and the availability
of endocan level in determining the severity of the disease.
Patients and methods : A total of 42 patients with pancreatitis
and 33 healthy individuals were included in the study. The serum
endocan levels in patients were evaluated 1st and 3 th days after
the symptom’s onset. Current scoring systems and the relationship
between the severity of the disease and endocan levels were
Results : The endocan levels of the patients on day 1 are
significantly correlated only with the APACHE II score (p=0.039
r=0.319), while the endocan values on day 3 are significantly
correlated with the BISAP (bedside index of severity in acute
pancreatitis) (p=0.013 r=0.380), APACHE II (Acute Physiology and
Chronic Health Evaluation)(p<0.001; r=0.53) and Ranson (p=0.037
r=0.32) scores. The cutoff level of endocan (day 3) was calculated
92.2 pg/ml (83% sensitivity and 50% specificity; p=0.039 area
under the curve 0.706) for severe pancreatitis when considering
the patients with a score of 8 or higher in the APACHE II scoring
Conclusion : Serum endocan level can be used as a marker of
prognosis in patients with pancreatitis. However, studies involving
large populations are needed on this matter.
Uptake of hepatitis C virus screening and treatment in persons under opioid substitution therapy between 2008 and 2013 in Belgium
Background : Hepatitis C is a viral infection caused by the
hepatitis C virus (HCV) with people who inject drugs as the main
group at risk worldwide.
Aim : This study investigated the differences in uptake for HCV
screening and treatment between persons in opioid substitution
therapy (OST) and the other members of the Christian Health
Insurance Fund in Belgium.
Methods : Invoice data were retrospectively collected from
the Christian Health Insurance Fund, representing 42% of
the healthcare users. Information on demographics, screening,
diagnostic tests, treatment and disease progression was obtained
from 2008 till 2013. All people in this study were aged 20-65 year.
Persons in the OST group were identified as having at least one
prescription reimbursed for methadone. This group was compared
to the other members of the Insurance Fund not on OST (NOST).
Results : The Insurance Fund registered 8,409 unique OST and
3,525,190 members in the general group. HCV RNA screening rate
was higher in the OST group after correction for age and gender
(4.3% vs. 0.2%). Ribavirin reimbursement, did not differ between
the OST and NOST group screened for HCV RNA (16.9% vs.
14.4%), though the probability of having ribavirin reimbursed
was smaller for females than for males. Procedures concerning
disease progression were reimbursed less frequently in the HCV
RNA screened OST group compared to the NOST group (0.3% vs.
Conclusion : People on OST were screened more often for
HCV RNA. However, the general uptake for HCV screening
and treatment in both populations remained suboptimal.