Upper Gastrointestinal Endoscopy Quality in Italy: A Nationwide Study.

BACKGROUND AND AIMS: International guidelines advise improving esophagogastroduodenoscopy (EGD) quality in Western countries, where gastric cancer is still diagnosed in advanced stages. This nationwide study investigated some indicators for the quality of EGD performed in endoscopic centers in Italy. METHODS: Clinical, endoscopic, and procedural data of consecutive EGDs performed in one month in the participating centers were reviewed and collected in a specific database. Some quality indicators before and during endoscopic procedures were evaluated. RESULTS: A total of 3,219 EGDs performed by 172 endoscopists in 28 centers were reviewed. Data found that some relevant information (family history for GI cancer, smoking habit, use of proton pump inhibitors) were not collected before endoscopy in 58.5-80.7% of patients. Pre-endoscopic preparation for gastric cleaning was routinely performed in only 2 (7.1%) centers. Regarding the procedure, sedation was not performed in 17.6% of patients, and virtual chromoendoscopy was frequently (>75%) used in only one (3.6%) center. An adequate sampling of the gastric mucosa (i.e., antral and gastric body specimens) was heterogeneously performed, and it was routinely performed only by 23% of endoscopists, and in 14.3% centers. CONCLUSIONS: Our analysis showed that the quality of EGD performed in clinical practice in Italy deserves to be urgently improved in different aspects.

Endoscopic characterization of neoplastic and non-neoplastic lesions in inflammatory bowel disease: systematic review in the era of advanced endoscopic imaging.

Background: Current guidelines strongly recommend the use of validated classifications to support optical diagnosis of lesions with advanced endoscopic imaging in the lower gastrointestinal tract. However, the optimal strategy in inflammatory bowel disease (IBD) is still a matter of debate. Objectives: To analyze the accuracy of endoscopic classifications or single predictors for in vivo lesion characterization during endoscopic surveillance of IBD with advanced endoscopic imaging. Design: Systematic review. Data sources and methods: Medline and PubMed were used to extract all studies which focused on lesion characterization of neoplastic and non-neoplastic lesions in IBD. The diagnostic accuracy of endoscopic classifications and single endoscopic predictors for lesion characterization were analyzed according to type of patients, lesions, and technology used. When available, the rates of true and false positives or negatives for neoplasia were pooled and the sensitivity (SE), specificity (SP), positive predictive value, and negative predictive value (NPV) were calculated. Results: We included 35 studies (2789 patients; 5925 lesions - 1149 neoplastic). Advanced endoscopic imaging included dye-based chromoendoscopy, virtual chromoendoscopy (VCE), magnification and high-definition endoscopy, confocal laser endomicroscopy (CLE), endocytoscopy, and autofluorescence imaging. The Kudo classification of pit patterns was most frequently used, with pooled SE 83%, SP 83%, and NPV 95%. The endoscopic criteria with the highest accuracy, with minimum SE ⩾ 90%, SP ⩾ 80%, and NPV ⩾ 90% were: the Kudo-IBD classification used with VCE (Fuji Intelligent Color Enhancement and i-SCAN); combined irregular surface and vascular patterns used with narrow band imaging; the Mainz classification used with CLE. Multiple clinical and technical factors were found to influence the accuracy of optical diagnosis in IBD. Conclusion: No single endoscopic factor has yet shown sufficient accuracy for lesion characterization in IBD surveillance. Conventional classifications developed in the non-IBD setting have lower accuracy in IBD. The use of new classifications adapted for IBD (Kudo-IBD), and new technologies based on in vivo microscopic analysis show promise.

Continuous clinical remission with biologics in ulcerative colitis: the 'AURORA' comparison study.

OBJECTIVES: Comparative trials among biological drugs for the treatment of ulcerative colitis (UC) provided conflicting results. After patent expire of infliximab originator, adalimumab, infliximab biosimilar, golimumab and vedolizumab have been approved in Italy.We compared the efficacy of these four biologics in UC according to the concept of continuous clinical remission (CCR). METHODS: In a retrospective, multicentre study, all UC patients treated with adalimumab, infliximab biosimilar, golimumab or vedolizumab between 2014 and 2019 were included. All drugs were compared to each other according to the 1-year CCR rate, defined as Mayo partial score ≤2, with bleeding subscore = 0, without any relapse or optimization with dose escalation, topical treatments or steroid use after first clinical remission. RESULTS: Four-hundred sixteen patients (adalimumab = 90, infliximab biosimilar = 105, golimumab = 79, vedolizumab = 142) were included. CCR was achieved in similar percentages among the groups (33%, 37%, 28%, 37%, respectively). All drugs were equivalent in biologic-naive patients, while vedolizumab was better than a second anti-TNFα in prior anti-TNFα agent failures. No differences were found according to type of adverse events or severe adverse events. CONCLUSIONS: Based on a strict definition of clinical remission, all biologics appear equally effective at 1 year. Changing to vedolizumab is more effective than switching to another anti-TNFα in TNFα failures.

Evidence-based efficacy of methotrexate in adult Crohn's disease in different intestinal and extraintestinal indications.

Introduction: Methotrexate (MTX) is included in the therapeutic armamentarium of Crohn's disease (CD), although its positioning is currently uncertain in an era in which many effective biological drugs are available. No systematic reviews or meta-analysis have stratified the clinical outcomes of MTX according to the specific clinical scenarios of its use. Methods: Medline, PubMed and Scopus were used to extract eligible studies, from database inception to May 2021. A total of 163 studies were included. A systematic review was performed by stratifying the outcomes of MTX according to formulation, clinical indication and criteria of efficacy. Results: The use of MTX is supported by randomized clinical trials only in steroid-dependent CD, with similar outcomes to thiopurines. The use of MTX in patients with steroid-refractoriness, failure of thiopurines or in combination with biologics is not supported by high levels of evidence. Combination therapy with biologics can optimize the immunogenic profile of the biological drug, but the impact on long-term clinical outcomes is described only in small series with anti-TNFα. Other off-label uses, such as fistulizing disease, mucosal healing, postoperative prevention and extraintestinal manifestations, are described in small uncontrolled series. The best performance in most indications was shown by parenteral MTX, favouring higher doses (25 mg/week) in the induction phase. Discussion: Evidence from high-quality studies in favour of MTX is scarce and limited to the steroid-dependent disease, in which other drugs are the leading players today. Many limitations on study design have been found, such as the prevalence of retrospective underpowered studies and the lack of stratification of outcomes according to specific types of patients and formulations of MTX. Conclusion: MTX is a valid option as steroid-sparing agent in steroid-dependent CD. Numerous other clinical scenarios require well-designed clinical studies in terms of patient profile, drug formulation and dosage, and criteria of efficacy.

Transcatheter Arterial Embolization in Acute Non-Variceal Gastrointestinal Bleedings: A Ten-Year Single-Center Experience in 91 Patients and Review of the Literature.

OBJECTIVE: To report the safety and efficacy of trans-arterial embolization (TAE) for upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB) due to different etiologies in 91 patients for ten years. METHODS: A retrospective analysis of GIB treated between January 2010 and December 2020 was performed. TAE was performed using different embolic agents (coils, particles, glue, gelatin sponge, and EVOH-based agents). Technical success, secondary technical success, clinical success, and complications were evaluated. RESULTS: Technical success was achieved in 74/91 (81.32%) patients. Seventeen patients (18.68%) required re-intervention. Secondary technical success was achieved in all cases (100.0%). Clinical success was achieved in 81/91 patients (89.01%). No major complications were recorded; overall, minor complications occurred in 20/91 patients. CONCLUSIONS: TAE is a technically feasible and safe therapeutic option for patients with GIB from a known or blind anatomic source where endoscopic therapy has failed or is deemed unfeasible.

A multicenter survey on endoscopic retrograde cholangiopancreatography during the COVID-19 pandemic in northern and central Italy.

Background and study aims COVID-19 has dramatically impacted endoscopy practice because upper endoscopy procedures can be aerosol-generating. Most elective procedures have been rescheduled. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in emergency or urgent settings in which rescheduling is not possible. We evaluated the impact of the COVID-19 pandemic on ERCP in Italy during the SARS-CoV-2 lockdown, in areas with high incidence of COVID-19. Patients and methods We performed a retrospective survey of centers performing ERCP in high COVID-19 prevalence areas in Italy to collect information regarding clinical data from patients undergoing ERCP, staff, case-volume and organization of endoscopy units from March 8, 2020 to April 30, 2020. Results We collected data from 31 centers and 804 patients. All centers adopted a triage and/or screening protocol for SARS-CoV-2 and performed follow-up of patients 2 weeks after the procedure. ERCP case-volume was reduced by 44.1 % compared to the respective 2019 timeframe. Of the 804 patients undergoing ERCP, 22 (2.7 %) were positive for COVID-19. Adverse events occurred at a similar rate to previously published data. Of the patients, endoscopists, and nurses, 1.6 %, 11.7 %, and 4.9 %, respectively, tested positive for SARS-CoV-2 at follow up. Only 38.7 % of centers had access to a negative-pressure room for ERCP. Conclusion The case-volume reduction for ERCP during lockdown was lower than for other gastrointestinal endoscopy procedures. No definitive conclusions can be drawn about the percentage of SARS-CoV-2-positive patients and healthcare workers observed after ERCP. Appropriate triage and screening of patients and adherence to society recommendations are paramount.

Clinical management and patient outcomes of acute lower gastrointestinal bleeding. A multicenter, prospective, cohort study.

BACKGROUND & AIM: Although acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management. METHODS: Adult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded. RESULTS: Overall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5-4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients. CONCLUSION: Mortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT04364412].

Infection Control Practices and Outcomes of Endoscopy Units in the Lombardy Region of Italy: A Survey From the Italian Society of Digestive Endoscopy During COVID-19 Spread.

GOALS: The present survey from the Italian Society of Digestive Endoscopy (SIED-Società Italiana di Endoscopia Digestiva) was aimed at reporting infection control practice and outcomes at Digestive Endoscopy Units in a high-incidence area. BACKGROUND: Lombardy was the Italian region with the highest coronavirus disease-2019 (COVID-19) prevalence, at the end of March 2020 accounting for 20% of all worldwide deaths. Joint Gastro-Intestinal societies released recommendations for Endoscopy Units to reduce the risk of the contagion. However, there are few data from high-prevalence areas on adherence to these recommendations and on their efficacy. METHODS: A survey was designed by the Lombardy section of SIED to analyze (a) changes in activity and organization, (b) adherence to recommendations, (c) rate of health care professionals' (HCP) infection during the COVID-19 outbreak. RESULTS: In total, 35/61 invited centers (57.4%) participated; most modified activities were according to recommendations and had filtering face piece 2/filtering face piece 3 and water-repellent gowns available, but few had negative-pressure rooms or provided telephonic follow-up; 15% of HCPs called in sick and 6% had confirmed COVID-19. There was a trend (P=0.07) toward different confirmed COVID-19 rates among endoscopists (7.9%), nurses (6.6%), intermediate-care technicians (3.4%), and administrative personnel (2.2%). There was no correlation between the rate of sick HCPs and COVID-19 incidence in the provinces and personal protective equipment availability and use, whereas an inverse correlation with hospital volume was found. CONCLUSIONS: Adherence to recommendations was rather good, though a minority were able to follow all recommendations. Confirmed COVID-19 seemed higher among endoscopists and nurses, suggesting that activities in the endoscopy rooms are at considerable viral spread risk.

CELL THERAPY IN INFLAMMATORY BOWEL DISEASE.

In recent years, cell-based therapies have been explored in various immune-mediated inflammatory diseases, including inflammatory bowel disease (IBD). Cell therapy is the process of introducing new cells into an organism or tissue in order to treat a disease. The most studied cellular treatment in IBD was "stem cells-based therapy", which was explored according to different protocols in terms of type of donors, stem cells sources, study design and clinical endpoints. More recently, preliminary studies have also described the clinical use of "regulatory cells", which include T-reg and Tr1 cells, and "tolerogenic" dendritic cells. Finally, induced pluripotent stem cells are the subject of an intensive preclinical research program on animal models, including those related to colitis.

Laparoscopic Approach to Large Bowel Neoplastic Obstruction After Self-Expandable-Metal-Stent (SEMS) Placement.

Endoscopic self-expandable metal stent (SEMS) placement as a bridge to surgery in large bowel neoplastic obstruction is an alternative to emergency surgery for the obstructive colorectal neoplasms. This study aims to analyze postoperative and long-term outcomes in a series of patients who underwent laparoscopic colorectal resection after SEMS placement. The analysis, after the stratification based on the time elapsed between the onset of the occlusive symptoms and the SEMS positioning, revealed an interesting result, with lower mortality for patients who underwent the procedure within 24 hours of hospitalization (P=0.0159). This trend may indicate the need to reduce the endoscopic time schedules as much as possible, even if an emergency procedure is needed. The laparoscopic approach, after stent placement as bridge therapy, can be a safe alternative to emergency surgery, if the procedure is precociously applied.

Periendoscopic management of direct oral anticoagulants: a prospective cohort study.

OBJECTIVE: To assess the frequency of adverse events associated with periendoscopic management of direct oral anticoagulants (DOACs) in patients undergoing elective GI endoscopy and the efficacy and safety of the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) recommendations (NCT02734316). DESIGN: Consecutive patients on DOACs scheduled for elective GI endoscopy were prospectively included. The timing of DOAC interruption and resumption before and after the procedures were recorded, along with clinical and procedural data. Procedures were stratified into low-risk and high-risk for GI-related bleeding, and patients into low-risk and high-risk for thromboembolic events. Patients were followed-up for 30 days for major and clinically relevant non-major bleeding events (CRNMB), arterial and venous thromboembolism and death. RESULTS: Of 529 patients, 38% and 62% underwent high-risk and low-risk procedures, respectively. There were 45 (8.5%; 95% CI 6.3% to 11.2%) major or CRNMB events and 2 (0.4%; 95% CI 0% to 1.4%) thromboembolic events (transient ischaemic attacks). Overall, the incidence of bleeding events was 1.8% (95% CI 0.7% to 4%) and 19.3% (95% CI 14.1% to 25.4%) in low-risk and high-risk procedures, respectively. For high-risk procedures, the incidence of intraprocedural bleeding was similar in patients who interrupted anticoagulation according to BSG/ESGE guidelines or earlier (10.3%vs10.8%, p=0.99), with a trend for a lower risk as compared with those who stopped anticoagulation later (10.3%vs25%, p=0.07). The incidence of delayed bleeding appeared similar in patients who resumed anticoagulation according to BSG/ESGE guidelines or later (6.6%vs7.7%, p=0.76), but it tended to increase when DOAC was resumed earlier (14.4%vs6.6%, p=0.27). The risk of delayed major bleeding was significantly higher in patients receiving heparin bridging than in non-bridged ones (26.6%vs5.9%, p=0.017). CONCLUSION: High-risk procedures in patients on DOACs are associated with a substantial risk of bleeding, further increased by heparin bridging. Adoption of the BSG/ESGE guidelines in periendoscopic management of DOACs seems to result in a favourable benefit/risk ratio. TRIAL REGISTRATION NUMBER: NCT02734316; Pre-results.

Point Shear Wave Elastography of the Spleen: Its Role in Patients with Portal Hypertension.

The goals of the study described here were to evaluate the feasibility and reproducibility of measuring spleen stiffness (SS) using point shear wave elastography in a series of cirrhotic patients and to investigate whether SS, liver stiffness (LS) and other non-invasive parameters are correlated with the presence of esophagogastric varices (EVs). Fifty-four cirrhotic patients with low-grade EVs or without EVs at esophago-gastro-duodenoscopy were enrolled. They underwent abdominal ultrasound and Doppler ultrasound of hepatic vessels simultaneously with p-SWE of the liver and spleen. In 42 patients, the accuracy of LS and SS, as well as of platelet count and spleen longitudinal diameter, in predicting the presence of EVs was evaluated. The technical success was 90.74% for LS (49/54 patients) and 77.78% for SS (42/54 patients). Inter-observer agreement for SS measurement was high. Both LS and SS correlated with esophago-gastro-duodenoscopy: LS had the highest accuracy in predicting the presence of EVs (area under the receiver operating characteristic curve [AUROC] = 0.913); SS had the lowest accuracy (AUROC = 0.675); platelet count and spleen diameter had intermediate accuracy (AUROC = 0.731 and 0.729, respectively). SS did not have an advantage over LS in predicting low-grade EVs and cannot be proposed as a useful tool in the diagnostic process of cirrhotic patients who require screening esophago-gastro-duodenoscopy.

Evidence for the Presence of Non-Celiac Gluten Sensitivity in Patients with Functional Gastrointestinal Symptoms: Results from a Multicenter Randomized Double-Blind Placebo-Controlled Gluten Challenge.

Non-celiac gluten sensitivity (NCGS) is characterized by the onset of symptoms after eating gluten-containing food. We aimed to single out NCGS subjects among subjects with functional gastrointestinal symptoms. Patients were enrolled in a multicenter double-blind placebo-controlled trial with crossover. Symptoms and quality of life were evaluated by means of 10-cm VAS and SF36. Iron parameters, transaminases and C reactive protein (CRP) were evaluated. After a three-week-long gluten-free diet (GFD), responsive patients were randomly assigned to gluten intake (5.6 g/day) or placebo for seven days, followed by crossover. The primary endpoint was the worsening of symptoms (VAS increase ≥3 cm) during gluten ingestion compared to placebo. One hundred and forty patients were enrolled and 134 (17 males, mean age 39.1 ± 11.7 years, BMI 22.4 ± 3.8) completed the first period. A total of 101 subjects (10 males, mean age 39.3 ± 11.0 years, BMI 22.3 ± 4.0) reported a symptomatic improvement (VAS score 2.3 ± 1.2 vs. 6.5 ± 2.2 before and after GFD, p = 0.001). 98 patients underwent the gluten challenge and 28 (all females, mean age 38.9 ± 12.7 years, BMI 22.0 ± 2.9) reported a symptomatic relapse and deterioration of quality of life. No parameters were found to be statistically associated with positivity to the challenge. However, 14 patients responded to the placebo ingestion. Taking into account this finding, about 14% of patients responding to gluten withdrawal showed a symptomatic relapse during the gluten challenge. This group is suspected to have NCGS.

Laparoscopic repair of voluminous symptomatic hiatal hernia using absorbable synthetic mesh.

INTRODUCTION: Hiatal hernia is a common disorder and a controversial topic. In symptomatic voluminous hernias laparoscopic surgery and use of mesh can be considered. An initial experience in voluminous hiatal hernia laparoscopic repair using absorbable glycolic acid/trimethylene carbonate synthetic mesh is reported. MATERIAL AND METHODS: Retrospective study from an institutional database was performed to analyze laparoscopic hiatal hernia repair using absorbable synthetic mesh from January 2010 to December 2013. All preoperative symptoms and exams were collected and a standardized procedure was performed. Clinical and radiological follow-up was performed. RESULTS: Eight patients underwent laparoscopic repair of hiatal hernia performed by two highly skilled laparoscopic surgeons. One Toupet and seven Nissen fundoplications were tailored. No conversions into laparotomy, neither intraoperative complications nor mortality occurred. After a median follow-up of 23.5 months (range 14 - 44) no mesh complications occurred and all patients are asymptomatic. Two radiological recurrences (25%) were detected. CONCLUSIONS: Voluminous symptomatic hiatal hernias can be successfully treated in a high-volume and long-term experienced laparoscopic surgical center by the use of an absorbable synthetic mesh. Further studies and a longer-term follow-up are necessary to confirm this preliminary report.

The use of a pocket-sized ultrasound device improves physical examination: results of an in- and outpatient cohort study.

BACKGROUND: The performance of pocket mobile ultrasound devices (PUDs) is comparable with that of standard ultrasonography, whereas the accuracy of a physical examination is often poor requiring further tests to assess diagnostic hypotheses. Adding the use of PUD to physical examination could lead to an incremental benefit. AIM: We assessed whether the use of PUD in the context of physical examination can reduce the prescription of additional tests when used by physicians in different clinical settings. METHODS: We conducted a cohort impact study in four hospital medical wards, one gastroenterological outpatient clinic, and 90 general practices in the same geographical area. The study involved 135 physicians who used PUD, after a short predefined training course, to examine 1962 consecutive patients with one of 10 diagnostic hypotheses: ascites, pleural effusion, pericardial effusion, urinary retention, urinary stones, gallstones, biliary-duct dilation, splenomegaly, abdominal mass, abdominal aortic aneurysm. According to the physicians' judgment, PUD examination could rule out or in the diagnostic hypothesis or require further testing; the concordance with the final diagnosis was assessed. The main outcome was the proportion of cases in which additional tests were required after PUD. The PUD diagnostic accuracy was assessed in patients submitted to further testing. FINDINGS: The 1962 patients included 37% in-patients, 26% gastroenterology outpatients, 37% from general practices. Further testing after PUD examination was deemed unnecessary in 63%. Only 5% of patients with negative PUD not referred for further testing were classified false negatives with respect to the final diagnosis. In patients undergoing further tests, the sensitivity was 91%, and the specificity 83%. CONCLUSIONS: After a simple and short training course, a PUD examination can be used in addition to a physical examination to improve the answer to ten common clinical questions concerning in- and outpatients, and can reduce the need for further testing.

A multicentre case control study on complicated coeliac disease: two different patterns of natural history, two different prognoses.

BACKGROUND: Coeliac disease is a common enteropathy characterized by an increased mortality mainly due to its complications. The natural history of complicated coeliac disease is characterised by two different types of course: patients with a new diagnosis of coeliac disease that do not improve despite a strict gluten-free diet (type A cases) and previously diagnosed coeliac patients that initially improved on a gluten-free diet but then relapsed despite a strict diet (type B cases). Our aim was to study the prognosis and survival of A and B cases. METHODS: Clinical and laboratory data from coeliac patients who later developed complications (A and B cases) and sex- and age-matched coeliac patients who normally responded to a gluten-free diet (controls) were collected among 11 Italian centres. RESULTS: 87 cases and 136 controls were enrolled. Complications tended to occur rapidly after the diagnosis of coeliac disease and cumulative survival dropped in the first months after diagnosis of complicated coeliac disease. Thirty-seven cases died (30/59 in group A, 7/28 in group B). Type B cases presented an increased survival rate compared to A cases. CONCLUSIONS: Complicated coeliac disease is an extremely serious condition with a high mortality and a short survival. Survival depends on the type of natural history.

Usefulness and safety of biliary percutaneous transluminal forceps biopsy (PTFB): our experience.

AIM: To evaluate the usefulness and safety of percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction. MATERIAL AND METHODS: Forty consecutive patients (21 men and 19 women; mean age, 71.9 years) underwent forceps biopsy through percutaneous transhepatic biliary access performed to drain bile. Lesions involved the common bile duct (n 8), common hepatic duct (n 18), hilum (n 6), ampullary segment of the common bile duct (n 8) and were biopsied with 7-F biopsy forceps. Final diagnosis was confirmed with pathologic findings at surgery, or clinical and radiologic follow-up. RESULTS: Twenty-one of 40 biopsies resulted in correct diagnosis of malignancy. Thirteen biopsy diagnosis were proved to be true-negative. There were six false-negative and no false-positive diagnoses. Sensitivity, specificity and accuracy in aspecific biliary obstructions were 85%, 100% and 88,7% respectively. Sensitivity of biopsy in malignancies was higher than in benign obstructions (100% vs 68,4%, CI = 95%). Sensitivity was lower in the hilum tract and in the common bile duct than in other sites (CI = 95%). No major complications related to biopsy procedures occurred. CONCLUSIONS: Percutaneous transluminal forceps biopsy is a safe procedure, easy to perform through a transhepatic biliary drainage tract, providing high accuracy in the diagnosis of malignant biliary obstructions.

Cerebral arterial thrombosis in ulcerative colitis.

Thrombosis, mainly venous, is a rare and well-recognized extraintestinal manifestation of inflammatory bowel disease (IBD). We describe a 25-year-old Caucasian man affected by ulcerative colitis and sclerosing cholangitis with an episode of right middle cerebral arterial thrombosis resolved by intraarterial thrombolysis. We perform a brief review of the International Literature.

Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones.

PURPOSE OF THE STUDY: To report our experience in treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL). PATIENTS AND METHODS: Ten symptomatic patients with intrahepatic or common bile duct calculi underwent PTBL. Six of these patients had previously undergone unsuccessful endoscopic treatment; four patients were declared not suitable for endoscopic procedure. PTBL was performed with a flexible choledochoscopy inserted by way of the percutaneous access sheath. A holmium laser was used to fragment the biliary stones. Sphincteroplasty was performed when considered necessary and an occlusion balloon for the clearance of common bile duct (CBD) calculi was used when continuous warm saline irrigation at high pressure was not sufficient. Clinical follow up was performed by the referring physician. Technical success, clinical success and complications were evaluated. MAIN FINDINGS: Technical success rate was 100%. The overall clinical success rate was 100%. No patients underwent additional procedures for retained stones or developed de novo strictures or other complications related to the procedure. Hospital stay was no more than 4 days after the procedure. Duration of follow-up was 6-25 months (mean 12.6). One patient died from unrelated causes. During this period, no recurrence and/or complications related to procedure were observed. No major complications were registered. Minor complications like temporary abdominal pain were considered not significant by the patients. CONCLUSIONS: Complicated or large biliary calculi can be treated successfully using PTBL. In selected patients, this approach should become the first choice of treatment after other treatments are rejected.

Free circulating DNA as a biomarker of colorectal cancer.

OBJECTIVES: The purpose of this study is to evaluate the sensitivity and specificity of free circulating DNA (FCDNA) as a biomarker in patients suffering from colorectal cancer (CRC), investigating both its prognostic value correlated with stage of disease and its potential role in early recurrence diagnosis. METHODS: The quantification of plasma DNA was achieved through the use of real time quantitative polymerase chain reaction (PCR) amplification of the RNAse P gene. The study enrolled patients undergoing surgery for primary CRC, at different stages of disease; samples were collected before surgery and during follow-up examinations every 3 months after surgery. Data were statistically analyzed using Software Packages SPSS® for Windows. RESULTS: FCDNA was detectable in all pre-operative samples and the mean value was 47.8 ng/mL. FCDNA values increased progressively related to UICC stage of disease, although statistical significance was demonstrated only when comparing patients by pT stage. The analysis of postoperative samples showed a significant decrease of FCDNA quantity after radical surgery and in specific cases a rise preceding disease recurrence. CONCLUSIONS: This study shows that absolute quantification of FCDNA in CRC patients could have a prognostic value, being related to stage of disease, and could be used as potential tool for early detection of recurrences.