Gastritis staging in the endoscopic follow-up for the secondary prevention of gastric cancer: a 5-year prospective study of 1755 patients.

OBJECTIVE: Operative link on gastritis assessment (OLGA) staging for gastritis ranks the risk for gastric cancer (GC) in progressive stages (0-IV). This prospective study aimed at quantifying the cancer risk associated with each gastritis stage. DESIGN: A cohort of 1755 consecutive patients with dyspepsia underwent initial (T-0) oesophagogastroduodenoscopy with mapped gastric biopsies, OLGA staging and assessment of Helicobacter pylori infection. Patients were followed for 55 months (median); patients with stages II III and IV underwent a second endoscopy/restaging (T-1), and those with stages 0 and I were followed clinically and through in-depth clinical and record checking. Endpoints were OLGA stage at T-1 and development of gastric epithelial neoplasia. RESULTS: At T-0, 77.6% of patients had stage 0, 14.4% stage I, 5.1% stage II, 2.1% stage III and 0.85% stage IV. H. pylori infection was detected in 603 patients at T-0 and successfully eradicated in 602 of them; 220 had a documented history of H. pylori eradication; and 932 were H. pylori naïve-negative. Incident neoplastic lesions (prevalence=0.4%; low-grade intraepithelial neoplasia (IEN)=4; high-grade IEN=1; GC=2) developed exclusively in patients with stages III-IV. The risk for epithelial neoplasia was null in patients at stages 0, I and II (95% CI 0 to 0.4), 36.5 per 1000 person-years in patients at stage III (95% CI 13.7 to 97.4) and 63.1 per 1000 person-years in patients at stage IV (95% CI 20.3 to 195.6). CONCLUSIONS: This prospective study confirms that OLGA staging reliably predicts the risk for development of gastric epithelial neoplasia. Although no neoplastic lesions arose in H. pylori-naïve patients, the H. pylori eradication in subjects with advanced stages (III-IV) did not abolish the risk for neoplastic progression.

Combination of transjugular intrahepatic portosystemic shunt and antegrade through-the-TIPS coil embolization for bleeding mixed-type ectopic ileal varices.

A 61-year-old man with alcoholic cirrhosis and a history of severe cholecystitis leading to secondary thrombosis of the recanalized paraumbilical vein was admitted to our hospital for recurrent gastrointestinal bleeding and severe anemia. Capsule endoscopy and CT angiography detected profuse bleeding in the proximal ileum from ectopic ileal varices. Hepatic venous-portal gradient (HVPG) measurement was consistent with severe portal hypertension. Persistent bleeding despite transjugular intrahepatic portosystemic shunt (TIPS) placement required a combined approach with antegrade through-the-TIPS coil embolization of the ileal varices.

Hepatitis C virus burden: Treating and educating people without prejudice.

BACKGROUND: Hepatitis C virus (HCV) infection has a worldwide incidence of 1.1%. In Italy, 60% of people who inject drugs (PWIDs) and are receiving assistance for substance use disorder are infected with HCV. However, this subset of patients has extremely limited access to care due to multiple factors, including alcohol abuse, psychological comorbidities, and homeless status. AIM: To describe the impact of our HCV-dedicated service for substance use disorder (SSUD) service on PWIDs receiving anti-HCV therapy. METHODS: A dedicated, multidisciplinary team was set up at the SSUD of Trento in October 2020 to provide antiviral treatment to HCV RiboNucleic Acid-positive patients with an active or previous history of substance abuse. The treatment was followed by a health education program. Patients were treated with Direct-Acting Antivirals (DAAs). Data were retrospectively analyzed to assess the efficacy of our dedicated program in terms of therapy completion, HCV eradication, and compliance (primary endpoint). The rate of HCV reinfection and DAA-related toxicity were also assessed (secondary endpoints). RESULTS: A total of 40 patients were enrolled in the study: 28 (70.0%) were treated with Sofosbuvir/Velpatasvir, while 12 (30.0%) received Glecaprevir/Pibrentasvir. At the time of inclusion in the study, 36 patients were receiving opioid agonist maintenance therapy, whilst another 4 had just finished the treatment. 37.5% had a history of alcoholism and 42.5% received concomitant psychiatric treatment. All 40 patients (100.0%) completed the therapy cycle and 92.5% of patients adhered to the program. All patients tested negative for viral load at the end of the treatment. There were no significant drug interactions with common psychiatric treatments and no side effects were observed. The sustained virological response was achieved in 92.5% of cases with good tolerability, although two patients discontinued treatment temporarily. After HCV eradication, one patient died from an overdose, another from complications of cirrhosis, and one reinfection occurred. CONCLUSION: Very high adherence to therapy and good tolerability was observed in our series of HCV patients treated at the SSUD, regardless of the substance abuse condition. Further validation in a larger population is required.

Clinical results of active scanning proton therapy for primary liver tumors.

BACKGROUND: Evidence for the efficacy of radiation therapy for primary liver cancer is growing. In this context, proton therapy (PT) can potentially improve the therapeutic ratio, as demonstrated by recent clinical studies. Here we report the first European clinical experience on the use of PT for primary liver cancer. METHODS: All patients treated for primary liver cancer in our center entered the analysis. Patients were simulated during deep expiration breath-hold. A 15-fraction treatment schedule was adopted using active scanning PT. Clinical outcome and toxicity were retrospectively analyzed. RESULTS: Between January 2018 and December 2019, 18 patients were treated. Fourteen patients had hepatocellular carcinoma (HCC), three patients had intrahepatic cholangiocarcinoma (ICC), and one patient had synchronous ICC-HCC. The Child-Pugh score was A5 in the majority of patients with HCC (71.4%). Median prescription dose was 58.05 Gy (range, 50.31-67.5). Median follow-up was 10 months (range, 1-19). The majority of deaths occurred from liver tumor progression. One-year overall survival (OS) was 63%. A significant correlation between worse OS and patient performance status, vascular invasion, and tumor stage was recorded. One-year local control was 90%. Toxicity was low, with a decrease in Child-Pugh score ⩾2 points detected in one patient. No cases of classic radiation-induced liver disease occurred. CONCLUSIONS: Our initial results of active scanning PT for primary liver cancer demonstrated the feasibility, safety, and effectiveness of this advanced technique in this setting. The potential of the combination of PT with other locoregional therapies is under evaluation.

Genetic polymorphism at the apolipoprotein E locus affects the outcome of chronic hepatitis B.

Apolipoprotein E (ApoE) and H (ApoH) genotypes are known to affect plasma lipoprotein concentrations. By modulating transport and entry of the hepatitis B virus into hepatocytes, apolipoproteins may influence the course of infection. To verify this hypothesis, 105 patients with chronic HBV infection were examined. Sixty-two of the patients were followed-up for a median time of 21 years. One hundred two controls were included. ApoE and ApoH genotypes were determined by the restriction fragment length polymorphism method. A trend was found for progressive overrepresentation of ApoE3/E3 among patients with advanced liver disease: 13/27 (48%) of inactive HBV carriers, 36/61 (59%) of chronic hepatitis B patients and 16/17 (94%) of patients who received liver transplants (P < 0.005). Being an E3/* carrier was associated with a lower probability of loss of HBsAg: 9/56 (16%) versus 3/6 (50%) (P < 0.05); it was also associated with a longer time before HBsAg loss (P < 0.05). No influence of ApoH genotypes on clinical outcomes was found. The probability of disease progression was higher, and that of loss of HBsAg was lower, among patients with the ApoE3 allelic variant. Downregulation and/or reduced binding of the LDL receptor may explain the more benign course of hepatitis B among carriers of ApoE2-E4.

Gastrointestinal tract injuries after thermal ablative therapies for hepatocellular carcinoma: A case report and review of the literature.

BACKGROUND: Radiofrequency ablation (RFA) and microwave ablation (MWA) represent the standard of care for patients with early hepatocellular carcinoma (HCC) who are unfit for surgery. The incidence of reported adverse events is low, ranging from 2.4% to 13.1% for RFA and from 2.6% to 7.5% for MWA. Gastrointestinal tract (GIT) injury is even more infrequent (0.11%), but usually requires surgery with an unfavourable prognosis. Due to its low incidence and the retrospective nature of the studies, the literature reporting this feared complication is heterogeneous and in many cases lacks information on tumour characteristics, comorbidities and treatment approaches. CASE SUMMARY: A 77-year-old man who had undergone extended right hepatectomy for HCC was diagnosed with early disease recurrence with a small nodule compatible with HCC in the Sg4b segment of the liver with a subcapsular location. He was treated with percutaneous RFA and a few week later he was urgently admitted to the Surgery ward for abdominal pain and fever. A subcutaneous abscess was diagnosed and treated by percutaneous drainage. A fistulous tract was then documented by the passage of contrast material from the gastric antrum to the abdominal wall. The oesophagogastroduodenoscopy confirmed a circular wall defect at the lesser curvature of gastric antrum, leading directly to the purulent abdominal collection. An over-the-scope clip (OTSC) was used to successfully close the defect. CONCLUSION: This is the first reported case of RFA-related GIT injury to have been successfully treated with an OTSC, which highlights the role of this endoscopic treatment for the management of this complication.

Appropriateness and yield of surveillance colonoscopy in first-degree relatives of colorectal cancer patients: A 5-year follow-up population-based study.

BACKGROUND AND AIMS: There are few prospective data about the use of surveillance colonoscopy and the risk of recurrent neoplasia in first degree relatives (FDRs) of colorectal cancer (CRC) patients. We examined the use and yield of surveillance colonoscopy in a population-based screening program (Trentino, Italy) METHODS: 1252 FDRs have been included in this study. We calculated compliance (percentage of FDRs who underwent surveillance colonoscopy among those eligible), appropriateness of colonoscopy (appropriate if performed within 6 months of the guidelines recommended interval) and diagnostic yield for neoplasia. We compared these data with those of 765 individuals without a family history (FH) of CRC who underwent screening colonoscopy in the same period (controls). RESULTS: Compliance and appropriateness were higher in FDRs than in controls (93.0% vs. 48.0%; p < 0.001; 59.6% vs. 18.8%; p < 0.0001, respectively). Younger age, female sex, FH of CRC and both non-advanced adenomas (nAA) and advanced adenomas (AA) at screening colonoscopy were predictors of appropriate surveillance. The cumulative incidence of nAA and AA was similar in FDRs and controls (31.7% and 4.9% in FDRs, including three invasive cancers; 32.4% and 5.8% in controls, respectively). CONCLUSION: FH does not increase the risk of AA in a 5-year follow-up; appropriate surveillance practices in FDRs could be highly expected in an organized screening program.

Clinical and radiological outcome of patients suffering from chronic pancreatitis associated with gene mutations.

OBJECTIVES: Cystic fibrosis transmembrane conductance regulator (CFTR), cationic trypsinogen gene (PRSS1), and serine protease inhibitor kazal type 1 (SPINK1) gene mutations have been associated with chronic pancreatitis (CP). The aim of this study was to compare clinical and radiological findings in sporadic CP with (CPgm) and without (CPwt) gene mutations. METHODS: Data from patients observed between 2001 and 2006 were collected. All patients were tested for 25 CFTR gene mutations, for R122H and N29I on the PRSS1 gene, and for N34S mutation on the SPINK1 gene. RESULTS: We found 34 (17.2%) of 198 patients with CPgm, 23 (11.6%) of them on the CFTR gene, 11 (5.6%) on the SPINK1, and none on the PRSS1 gene. The age at clinical onset was younger in CPgm (36.2 +/- 17.2 years) than in CPwt (44 +/- 12.6 years; P = 0.005). There were more heavy drinkers among CPwt (33%) than among CPgm (9%; P = 0.003), and the same applied to smokers (69% vs 33%, respectively; P < 0.0001). In CPgm group, the onset of pancreatic calcifications was observed more frequently in drinkers and/or smokers. Exocrine and endocrine insufficiency occurred less frequently and later in CPgm than in CPwt patients. CONCLUSIONS: Clinical and radiological outcome differ in CPgm compared with CPwt. Alcohol, even in small quantities, and cigarette smoking influence the onset of pancreatic calcifications.