Use of partially covered and uncovered metallic prosthesis for endoscopic ultrasound-guided hepaticogastrostomy: Results of a retrospective monocentric study.

BACKGROUND AND OBJECTIVES: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) represents an option to treat obstructive jaundice when endoscopic retrograde cholangiopancreatography (ERCP) fails. The success rate of this procedure has been shown to be very high. Up to now, plastic and self-expandable metallic stents (SEMSs) have been employed, each of them presenting some limitations. The aims of this study were to evaluate the technical and functional success rates of EUS-HGS using a dedicated biliary SEMS with a half-covered part (Giobor® stent). METHODS: We retrospectively reviewed data of patients, who underwent EUS-HGS at our center, with at least 6 months of follow-up. Demographic, clinical, and laboratory data were extracted from the patient's charts and electronic records. Technical success rate was defined as the successful passage of the Giobor stent across the stomach, along with the flow of contrast medium and/or bile through the stent. Functional success rate was considered achieved when the decrease of bilirubin value of at least 25% within the 1st week was obtained. The rate of early and late complications was assessed. RESULTS: A total of 41 patients were included (21F/20M, [mean age 66, range 45-85]). Technical success rate was obtained in 37 (90.2%) of patients. Functional success rate, analyzable in 29 patients, occurred in 65%. Between the 37 patients in whom HGS was technically feasible, 13 patients (31.7%) presented an early complication, mostly infective. At 6-month follow-up, 10/37 patients (27.0%) required a new biliary drainage (BD) and 11/37 (29.7%) died because of their disease. CONCLUSIONS: EUS-HGS using Giobor® stent is technically feasible, clinical effective, safe, and may be an alternative to percutaneous transhepatic BD in case of ERCP failure for biliary decompression.

Efficacy and safety in case of technical success of endoscopic ultrasound-guided transhepatic antegrade biliary drainage: A report of a monocentric study.

BACKGROUND AND OBJECTIVES: Endoscopic ultrasound (EUS)-guided biliary drainage techniques are alternative procedures in cases of obstructive jaundice with altered anatomy or failed ERCP. Complications related to EUS-guided antegrade drainage (EUS-AD) are still present in up to 10% of cases, and combination of procedures is sometimes suggested to avoid adverse events. The purpose of our study is to evaluate the efficacy and safety of EUS-AD with transhepatic access in case of technical success. METHODS: We retrospectively reviewed patients who underwent EUS-AD in a single, tertiary care center. RESULTS: Twenty patients were included (mean age 68), malignant stenosis in 95%. The reasons for EUS-AD were failed ERCP in 13/20, duodenal stenosis in 4/20, and altered anatomy after surgery in 3/20. A cystostome 6 Fr was always used to create the hepaticogastric tract, without puncture site closure. Self-expandable metallic stent (SEMS) was transpapillary in 95%. Drainage was completed in intraoperative stage by a EUS-hepaticogastrostomy (EUS-HGS) in 1/20 and by percutaneous drainage of the right liver (percutaneous transhepatic biliary drainage) in one out of 20. Overall clinical success was 17/20 (85%). One out of 20 presented a persistent obstructive cholangitis treated by another SEMS through ERCP. Two out of 20 patients died of infectious complications with incomplete drainage, in case of advanced neoplastic disease. One of these two patients was treated by EUS-AD and EUS-HGS at the same time. None of the 20 patients developed bilioma or bile leakage. CONCLUSION: EUS-AD by transhepatic way is clinically effective and safe. Closure of the gastric puncture site is not mandatory and complementary methods for biliary decompression should be combined in case of incomplete drainage and not to prevent potential adverse events.

Endotherapy in case of relapse of neoplastic Barrett's esophagus after successful initial endoscopic resection.

BACKGROUND: Endotherapy in cases of neoplastic Barrett esophagus (BE) relapse after successful initial endoscopic management is commonly accepted, but few studies analyze this topic and also take into account the metachronous lesions. AIMS: To evaluate the efficiency of endotherapy in the case of neoplastic BE relapse after successful complete endoscopic eradication of neoplastic BE and metaplastic BE. METHODS: Retrospective review of medical records was collected in a computerized and prospective manner between 2000 and 2015, in a single tertiary care center. Recurrence was defined by histological presence of high-grade dysplasia or superficial adenocarcinoma at least 6 months after the end of successful initial endotherapy. RESULTS: Eighteen patients were assessed (1F/17 M). Delay between initial treatment and relapse was 16.6 months (range 6-33). Endotherapy for relapse obtained a sustained and complete remission for 8/18 (44%) patients, with an average endoscopic follow-up of 28 months. The complication rate of endotherapy was 6%. Surgical management was required in 33% (2 pT2N0M0, 2 pTisN0M0, 1 pTm2N0M0 and 1 pTm3N0M0) and salvage radiochemotherapy in 17% (3/18). One patient treated by 6 sessions of ER was considered as a failure given the multiple sessions of endotherapy. Multivariate analysis showed that length of BE (>5 cm), late stenosis adverse events and the quality of vertical margin during initial ER are predictive factors for disease-free survival (p value < 0.01, Hazard Ratio up to 0.076). CONCLUSION: Endotherapy could be a treatment for management of neoplastic BE relapse, but should be carefully used, with strict follow-up.

Efficiency and safety of endoscopic resection in the management of subepithelial lesions of the stomach.

BACKGROUND: Gastric subepithelial tumors represent a diagnostic and therapeutic challenge, given their histologic heterogeneity and potential malignant behavior. OBJECTIVE: The objective of this article is to evaluate the interest, efficiency and safety of endoscopic resection for subepithelial gastric lesions of size <20 mm. METHODS: We conducted a single-center retrospective study in a tertiary care center. RESULTS: A total of 33 lesions (10 malignant/23 benign lesions) were studied. Mean histological size was 14.5 mm. Nine EMR, 18 ESD and six hybrid resections were performed. A total of 93.9% lesions were resected in one piece. At six months' follow-up, complete and definitive resection was obtained in 96.7% of cases. A vertical resection was insufficient in four cases. One GIST needed a complementary surgical resection, one neuroendocrine tumor was successfully treated by a new ESD session and two pancreatic rests were not additionally treated given the benign character and the absence of residual tissue in endoscopic control after six months. There was only one severe adverse event (2.9%); one pneumoperitoneum with ESD, three bleeding with one ESD and two EMR, always treated conservatively or endoscopically. CONCLUSION: Endoscopic resection is safe and should be the procedure of choice for both diagnosis and definitive resection of subepithelial gastric lesions of size under 20 mm.

Measurement of oro-caecal transit time by magnetic resonance imaging.

OBJECTIVES: To assess prospectively the agreement of orocaecal transit time (OCTT) measurements by lactulose hydrogen breath test (LHBT) and magnetic resonance imaging (MRI) in healthy subjects. METHODS: Volunteers underwent abdominal 1.5-T MRI using axial and coronal single-shot fast-spin-echo T2-weighted sequences, having fasted and after lactulose ingestion (10 g/125 mL). Imaging and H2 excretion gas-chromatography were performed concurrently every 15 min up to 180 min. MR images were analyzed using semiautomatic segmentation to calculate small bowel gas volume (SBGV) and visually to detect bolus arrival in the caecum. Agreement between MRI- and LHBT-OCTT was assessed. RESULTS: Twenty-eight subjects (17 men/11 women; mean age ± standard deviation 30 ± 8 years) were evaluated. Two H2 non-producers on LHBT were excluded. OCTT measured by MRI and LHBT was concordant in 18/26 (69 %) subjects (excellent agreement, k = 0.924). Median SBGV was 49.0 mL (interquartile interval 44.1 - 51.6 mL). In 8/26 (31 %) subjects, MRI showed that the lactulose bolus was in the terminal ileum and not the caecum when H2E increased on LHBT. Median OCTT measured by MRI was significantly longer than OCTT measured by LHBT [135 min (120 - 150 min) vs. 127.5 min (105 - 150 min); p = 0.008]. Above baseline levels, correlation between [H2] and SBGV was significant (r = 0.964; p < 0.001). CONCLUSIONS: MRI provides valid measurements of OCTT and gas production in the small bowel. KEY POINTS: • MRI is a valid technique to measure OCTT. • Excellent agreement between MRI and LHBT was found. • Measuring gas production using MRI may provide evidence of small bowel fermentation.

Granulo-monocyto apheresis is more effective in mild ulcerative colitis than in moderate to severe disease.

AIM: To evaluate whether the effectiveness of Granulo-monocyto apheresis (GMA), a technique that consists of the extracorporeal removal of granulocytes and monocytes from the peripheral blood, might vary according to the severity of ulcerative colitis (UC) in patients with mild to moderate-severe disease UC activity. METHODS: We retrospectively reviewed prospectively collected data of patients undergoing GMA at our inflammatory bowel disease centre who had at least a 6 mo of follow-up. The demographics, clinical and laboratory data were extracted from the patients' charts and electronic records. The severity of UC was scored according to the Modified Truelove Witts Severity Index (MTWSI). A clinical response was defined as a decrease from baseline of ≥ 2 points or a value of MTWSI ≤ 2 points. RESULTS: A total of 41 (24 males/17 females; mean age 47 years) patients were included in the study. After GMA cycle completion, 21/28 (75%) of mild UC patients showed a clinical response compared with 7/13 (54%) of patients with moderate to severe disease (P = 0.27). At 6-mo, 14/28 (50%) of the mild UC patients maintained a clinical response compared with 2/13 (15%) of the patients with moderate to severe disease (P = 0.04). After the GMA cycle completion and during the 6-mo follow up period, 13/16 (81%) and 9/16 (56%) of mild UC patients with intolerance, resistance and contraindications to immunosuppressants and/or biologics showed a clinical response compared with 2/6 (33%) and 0/6 (0%) of patients with moderate to severe disease activity with these characteristics (P = 0.05 and P = 0.04, respectively). CONCLUSION: Patients with mild UC benefit from GMA more than patients with moderate to severe disease in the short-term period. GMA should be considered a valid therapeutic option in cases of contraindications to immunosuppressants, corticosteroids and/or biologics.

Low serum trough levels are associated with post-surgical recurrence in Crohn's disease patients undergoing prophylaxis with adalimumab.

BACKGROUND: Whether therapeutic drug monitoring of biologic therapy can predict the efficacy of adalimumab to prevent postoperative Crohn's disease recurrence is unknown. AIM: To investigate whether adalimumab trough levels and anti-adalimumab antibodies correlate with endoscopic and clinical outcomes in a series of patients treated with prophylactic adalimumab monotherapy after resective surgery. METHODS: Post hoc analysis of a randomized, mesalamine-controlled trial. Adalimumab trough levels and antibodies were analysed every 8 weeks for 2 years using an homogeneous mobility shift assay. RESULTS: At two years, 1/6 patient had clinical recurrence and 1/6 patient had endoscopic and clinical recurrence. At baseline (9.5 vs. 14.4 mcg/mL) and during follow-up [7.5 (4.4-9.8) vs. 13.9 (8.9-23.6)mcg/mL, p<0.01], median adalimumab trough levels in patients with clinical or endoscopic recurrence were lower than in those who maintained remission. Persistent antibodies-against-adalimumab were detected in the patient with both endoscopic and clinical recurrence. CONCLUSION: Measurement of adalimumab trough levels and anti-adalimumab antibodies after surgery could be useful to further reduce postoperative recurrence.

Second-generation corticosteroids for the treatment of Crohn's disease and ulcerative colitis: more effective and less side effects?

BACKGROUND/AIMS: Systemic corticosteroids are highly effective at inducing clinical remission in cases of acute exacerbation of Crohn's disease (CD) and ulcerative colitis (UC); however, their use is limited by their frequent and sometimes severe side effects. Thus, a second generation of corticosteroids with less systemic effects has been developed. This review analyzed all of the studies on the new formulations of steroids with limited absorption (budesonide, budesonide MMX®, beclomethasone dipropionate and erythrocyte-mediated delivery of dexamethasone) in patients with CD and UC. METHODS: All relevant articles published in English between September 1960 and April 2011 were reviewed. RESULTS: Budesonide is superior to placebo, and as effective as systemic corticosteroids in inducing clinical remission in patients with ileo-colonic CD, but evidence of mucosal healing is limited. When administered as an MMX formula, budesonide can also effectively induce clinical remission in patients with UC, but budesonide alone is not effective in maintaining clinical remission in CD or UC. Beclomethasone dipropionate seems to be effective in patients with mild-to-moderate left-sided and extensive UC, while data on erythrocyte-mediated delivery of dexamethasone are encouraging but still limited. The safety profile for all these products is good but more studies are needed. CONCLUSION: Steroids remain the mainstay for the induction of clinical remission in cases of acute relapse of both CD and UC. Second-generation corticosteroids are an interesting alternative, with the advantage of high topical activity, less systemic toxicity and limited side effects.

Imaging modalities for perianal Crohn's disease.

Anorectal involvement in Crohn's disease (CD) causes perianal lesions that vary from simple asymptomatic skin tags, to complex disabling fistulas and abscesses. Perianal CD affects approximately one-third of patients; its management is challenging and may require combined medical and surgical treatment, which has proven to offer the best chance of success. An optimal preoperative disease assessment is crucial in order to achieve an optimal outcome and avoid irreversible damage due to incomplete or inaccurate intervention. Imaging modalities are useful in order to confirm diagnosis, to accurately classify the disease, as to plan the most suitable treatment and monitor its results. Endoscopic Ultrasonography (EUS) and pelvic Magnetic Resonance (MRI) represent the best options from this perspective, both in terms of sensitivity and specificity, as well as for their demonstrated role in influencing treatment approach. Transperineal Ultrasonography (TPUS) may be helpful when EUS is contraindicated or not-tolerated. Computed Tomography (CT) and fistulography are generally no longer considered due to their inferior performance and the radiation exposure they involve. All imaging should be done in conjunction with an Evaluation Under Anesthesia (EUA) performed by an expert surgeon, to ensure accurate disease assessment. In this paper we review available data on each imaging modality, comparing performance and focusing on specific pros and cons, in order to assist clinicians in choosing the most appropriate treatment option for each individual patient.

Trough levels and antibodies to infliximab may not predict response to intensification of infliximab therapy in patients with inflammatory bowel disease.

BACKGROUND: Infliximab is effective for the treatment of refractory inflammatory bowel disease (IBD). Nevertheless, up to 40% of patients lose response to infliximab over time. The aim was to assess the clinical value of measuring infliximab trough levels and antibodies to infliximab (ATI) concentrations in IBD patients who lost response to infliximab therapy. METHODS: We retrospectively studied records of IBD patients who lost response to infliximab therapy. We first assessed clinical responses of different therapeutic strategies that were applied when patients lost response to infliximab and then we looked at the correlation between clinical response and infliximab trough levels and ATI concentrations. RESULTS: Seventy-six IBD patients were included. 31/76 patients (41%) continued infliximab therapy without any modification, 39 patients (51%) had an intensification of infliximab therapy, five patients (7%) had switched to adalimumab therapy, and one patient (1%) underwent surgery. Clinical response was observed in 27 patients (69%) with an intensification of infliximab therapy. There was no significant difference in mean infliximab trough level at inclusion in patients who responded to intensification of infliximab therapy (3.3 ± 4.1 µg/mL) as compared with patients who did not respond (2.3 ± 2.2 µg/mL, P = 0.85). In all, 16/76 patients (22.4%) presented detectable ATI in the serum. Ten ATI-positive patients had an intensification of infliximab therapy and six (60%) demonstrated a clinical response. After intensification of infliximab therapy the ATI concentration decreased in five patients. CONCLUSIONS: In patients with IBD who lose response to infliximab, clinical improvement may occur upon intensification of infliximab therapy, irrespective of infliximab serum concentration or presence of ATI.

Successful treatment with adalimumab in a familial case of gastrointestinal Behcet's disease.

We present here two siblings with a history of recurrent oral and genital ulcers, neurological and gastrointestinal manifestations. The diagnosis of Behçet's disease in a context of familial aggregation was assumed. Facing repeated steroid-dependent flares and failure of maintenance therapies with colchicine and intolerance to pentoxifilline and disulone, adalimumab was started. Rapid response was observed in both patients, with clinical remission after induction therapy, which currently sustains under maintenance schedule. This case report suggests the effectiveness of adalimumab as first anti-TNFα in case of steroid-dependent/resistant gastrointestinal BD.

Editorial: Antibiotics earlier, IBD later?

Increasing evidence accumulates for a role of environmental factors in the onset of inflammatory bowel diseases (IBD). Among them, factors that might disturb the gut microflora hold an important place. As such, antibiotics deserve a special attention, and a possible association between their use, particularly during childhood, and the development of IBD, has been assessed by several authors since 1987. Results, conclusions, and possible impact of their observations, as well as perspectives for the future, are discussed here, in view of the article published in this issue of the Journal by Shaw et al.