ABSTRACT
BACKGROUND AND STUDY AIM: The traditional endoscopic therapy of anastomotic strictures (AS) after orthotopic liver transplantation (OLT) is multiple ERCPs with the insertion of an increasing number of plastic stents side-by-side. Fully covered self-expanding metal stents (cSEMS) could be a valuable option to decrease the number of procedures needed or non-responders to plastic stents. This study aims to retrospectively analyse the results of AS endoscopic treatment by cSEMS and to identify any factors associated with its success. PATIENTS AND METHODS: Ninety-one patients (mean age 55.9 ± 7.6 SD; 73 males) from nine Italian transplantation centres, had a cSEMS positioned for post-OLT-AS between 2007 and 2017. Forty-nine (54%) patients were treated with cSEMS as a second-line treatment. RESULTS: All the procedures were successfully performed without immediate complications. After ERCP, adverse events occurred in 11% of cases (2 moderate pancreatitis and 8 cholangitis). In 49 patients (54%), cSEMSs migrated. After cSEMS removal, 46 patients (51%) needed further endoscopic (45 patients) or radiological (1 patient) treatments to solve the AS. Lastly, seven patients underwent surgery. Multivariable stepwise logistic regression showed that cSEMS migration was the only factor associated with further treatments (OR 2.6, 95% CI 1.0-6.6; p value 0.03); cSEMS implantation before 12 months from OLT was associated with stent migration (OR 5.2, 95% CI 1.7-16.0; p value 0.004). CONCLUSIONS: cSEMS appears to be a safe tool to treat AS. cSEMS migration is the main limitation to its routinary implantation and needs to be prevented, probably with the use of new generation anti-migration stents.
Subject(s)
Cholestasis , Liver Transplantation , Cholangiopancreatography, Endoscopic Retrograde/adverse effects , Cholestasis/etiology , Cholestasis/surgery , Constriction, Pathologic/surgery , Humans , Liver Transplantation/adverse effects , Male , Middle Aged , Plastics , Retrospective Studies , Silicates , Stents/adverse effects , Treatment OutcomeABSTRACT
BACKGROUND: The most appropriate endo-therapeutic approach to biliary anastomotic strictures is yet to be defined. AIM: To retrospectively report on the endo-therapy of duct-to-duct anastomotic strictures during 2013 in Italy. METHODS: Data were collected from 16 Endoscopy Units at the Italian Liver Transplantation Centers (BASALT study group). RESULTS: Complete endo-therapy and follow-up data are available for 181 patients: 101 treated with plastic multistenting, 26 with fully covered self-expandable metal stenting and 54 with single stenting. Radiological success was achieved for 145 patients (80%), that is, 88% of plastic multistenting, 88% of self-expandable metal stenting and 61% of single stenting (P < 0.001 vs plastic multistenting; P < 0.05 vs self-expandable metal stenting). After first-line endo-therapy failure, the patients underwent a second-line endo-therapy with plastic multistenting for 25%, fully covered self-expandable metal stenting for 53% and single stenting for 22% of cases, and radiological success was achieved for 84%, that is, 100%, 85% and 63% with plastic multistenting, self-expandable metal stenting and single stenting (P < 0.05 vs plastic multistenting or self-expandable metal stenting) respectively. Procedure-related complications occurred in 7.8% of endoscopic retrograde cholangiopancreatographies. Overall, clinical success was achieved in 87% of patients after a median follow-up of 25 months. CONCLUSION: Plastic multistenting is confirmed as the preferred first-line treatment, while fully covered self-expandable metal stenting as rescue option for biliary anastomotic strictures. Single stenting has sub-optimal results and should be abandoned.
Subject(s)
Cholangiopancreatography, Endoscopic Retrograde/instrumentation , Constriction, Pathologic/surgery , Liver Transplantation/adverse effects , Self Expandable Metallic Stents , Stents/classification , Adult , Aged , Biliary Tract Diseases/etiology , Biliary Tract Diseases/surgery , Cholestasis/etiology , Constriction, Pathologic/etiology , Female , Humans , Italy , Liver Transplantation/mortality , Male , Middle Aged , Plastics , Retrospective Studies , Surveys and Questionnaires , Survival Analysis , Treatment Outcome , Young AdultABSTRACT
BACKGROUND AND AIMS: Self-expandable metal stents (SEMSs) are used to relieve malignant biliary obstructions. We aimed to compare stent patency, the adverse events rate, and overall survival of covered versus uncovered self-conformable metal stents in patients with primary malignant extrahepatic biliary strictures, not eligible for surgery. METHODS: This is a multicenter randomized trial analyzing 158 patients with inoperable distal malignant biliary obstruction conducted in 5 Italian referral centers between December 2014 and October 2016. Seventy-eight patients were randomized to receive a fully covered SEMS (FCSEMS), and 80 patients received uncovered SEMSs (USEMSs). Data from 148 (72 FCSEMSs and 76 USEMSs) of 158 patients were analyzed. RESULTS: Median time of stent patency was lower for FCSEMSs (240 days vs 541 days for USEMSs; P = .031). Adverse events occurred with 19 FCSEMSs (26.4%) and 10 USEMSs (13.2%); P = .061. The main causes of FCSEMS dysfunction were migration (7% vs 0% in the USEMS group) and early occlusion mainly because of sludge or overgrowth; late stent occlusion because of tumor ingrowth occurred in 13.2% of patients in the USEMS group. There were no significant differences either in levels of conjugated bilirubin improvement or in overall survival between the FCSEMS and USEMS groups. Median survival was 134 days in the FCSEMS group and 112 days in the USEMS group (P = .23). CONCLUSION: The number of stent-related adverse events was higher, although not significantly, among patients in the FCSEMS group. FCSEMSs had a significantly higher rate of migration than USEMSs, and stent occlusion occurred earlier. A significant difference in the patency rate was observed in favor of the USEMS group. (Clinical trial registration number: NCT02102984.).
Subject(s)
Biliary Tract Neoplasms/complications , Cholestasis, Extrahepatic/surgery , Drainage/instrumentation , Pancreatic Neoplasms/complications , Prosthesis Failure , Self Expandable Metallic Stents , Aged , Aged, 80 and over , Cholangiopancreatography, Endoscopic Retrograde , Cholestasis, Extrahepatic/etiology , Drainage/methods , Female , Humans , Male , Middle Aged , Palliative Care , Polytetrafluoroethylene , Prosthesis Failure/adverse effects , Self Expandable Metallic Stents/adverse effects , Survival Rate , Time Factors , Treatment OutcomeABSTRACT
OBJECTIVES: 2012 European Society of Pediatric Gastroenterology, Hepatology and Nutrition guidelines allow to establish a celiac disease diagnosis without duodenal biopsy in symptomatic pediatric patients with antitissue transglutaminase (anti-tTG) titers >10 times the upper limit of normal. For some years now, new chemiluminescence immunoassays have been made available: it is important to establish the clinical performance of anti-tTG and to determine the cut-off best suited to predict Marsh ≥2 to avoid gastrointestinal endoscopy not only in children, but also in the adult population. METHODS: A total of 2565 patients performed duodenal biopsy from July 2012 to September 2016; we selected all the patients who had undergone QUANTA Flash anti-tTG immunoglobulin A (IgA) within -3 months of duodenal biopsy and before the start of gluten-free diet. A total of 827 patients fulfilled the criteria for selection. RESULTS: Using a cut-off of 20 chemiluminescent unit (CU; area under the curve: 0.995), sensitivity, specificity, positive, and negative predictive value were 98.2%, 98.4%, 97.9%, and 98.6%, respectively. For the correlation with Marsh ≥2, in the pediatric population, positive predictive values (PPV) were 92.1%, 99%, and 100% at 200 CU (10×), 560 CU (28×), and 1000 CU (50×), respectively. In the adult population PPV was 94.2%, 98.2%, and 100% at 200 CU (10×), 350 CU (15×), and 400 CU (20×). CONCLUSIONS: Sensitivity, specificity, positive, and negative predictive value of QUANTA Flash h-tTG IgA were excellent. The cut-off providing an optimized PPV for histological lesions compatible for celiac disease (Marsh ≥2) for the QUANTA Flash h-tTG IgA is 350 CU (15×) in adult and 560 CU (28×) in children.
Subject(s)
Autoantibodies/blood , Celiac Disease/diagnosis , Immunoassay/methods , Immunoglobulin A/blood , Transglutaminases/immunology , Adolescent , Adult , Aged , Aged, 80 and over , Area Under Curve , Biopsy , Duodenum/pathology , Female , Humans , Luminescence , Male , Middle Aged , Retrospective Studies , Sensitivity and Specificity , Young AdultABSTRACT
BACKGROUND AND STUDY AIM: Precut sphincterotomy is a technique usually employed for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of bile duct disease. It is a validated risk factor for post-ERCP pancreatitis (PEP), but it is not clear whether the risk is related to the technique itself or to the repeated biliary cannulation attempts preceding it. The primary aim of the study was to assess the incidence of PEP in early precut compared with the standard technique in patients with difficult biliary cannulation. Secondary aims were to compare complications and cannulation success. PATIENTS AND METHODS: In this prospective, multicenter, randomized, clinical trial, patients who were referred for therapeutic biliary ERCP and difficult biliary cannulation were randomized to early precut (Group A) or repeated papillary cannulation attempts followed, in cases of failure, by late precut (Group B). PEP was defined as the onset of upper abdominal pain associated with an elevation in serum pancreatic enzymes of at least three times the normal level at more than 24 hours after the procedure. No rectal indomethacin or diclofenac was used for prevention of PEP. RESULTS: A total of 375 patients were enrolled. PEP developed in 10 of the 185 patients (5.4â%) in Group A and 23 of the 190 (12.1â%) in Group B (odds ratio [OR] 0.35; 95â% confidence interval [CI] 0.16â-â0.78). The incidence of PEP was significantly lower in the early precut group (10/185, 5.4â%) than in the delayed precut subgroup (19/135 [14.1â%]; OR 0.42, 95â%CI 0.17â-â1.07). There were no differences in biliary cannulation success rates, bleeding, perforation, and cholangitis. CONCLUSIONS: In patients with difficult biliary cannulation, early precut is an effective technique and can significantly reduce the incidence of PEP. Repeated biliary cannulation attempts are a real risk factor for this complication.
Subject(s)
Catheterization/adverse effects , Cholangiopancreatography, Endoscopic Retrograde/adverse effects , Pancreatitis/prevention & control , Postoperative Complications/prevention & control , Sphincterotomy, Endoscopic/methods , Aged , Aged, 80 and over , Common Bile Duct , Early Termination of Clinical Trials , Female , Humans , Male , Middle Aged , Pancreatitis/etiology , Postoperative Complications/etiology , Prospective Studies , Protective FactorsABSTRACT
We describe an unprecedented, disastrous complication after bilateral lung transplantation (BLT), a bilateral bronchial dehiscence with a right bronchoesophageal fistula leading to life-threatening septic shock. We also report the successful endoscopic management of this complication by double stenting and stress the efficacy of the multidisciplinary approach to this critical case.
Subject(s)
Bronchial Fistula/therapy , Bronchoscopy , Esophageal Fistula/therapy , Esophagoscopy , Lung Transplantation , Postoperative Complications/therapy , Self Expandable Metallic Stents , Bronchial Fistula/etiology , Esophageal Fistula/etiology , Female , Humans , Young AdultABSTRACT
OBJECTIVES: Data regarding agreement on endoscopic features of oesophageal varices in children with portal hypertension (PH) are scant. The aim of this study was to evaluate endoscopic visualisation and classification of oesophageal varices in children by several European clinicians, to build a rational basis for future multicentre trials. METHODS: Endoscopic pictures of the distal oesophagus of 100 children with a clinical diagnosis of PH were distributed to 10 endoscopists. Observers were requested to classify variceal size according to a 3-degree scale (small, medium, and large, class A), a 2-degree scale (small and large, class B), and to recognise red wales (presence or absence, class Red). Overall agreement was considered fair if Fleiss and Cohen κ test was ≥0.30, good if ≥0.40, excellent if ≥0.60, and perfect if ≥0.80. RESULTS: Agreement between observers was fair with class A (κâ=â0.34) and class B (κâ=â0.38), and good with class Red (κâ=â0.49). The agreement was good on presence versus absence of varices (class Aâ=â0.53, class Bâ=â0.48). The agreement among the observers was good in class A when endoscopic features of severe PH (medium and large sizes, red marks) were grouped and compared with mild features (absent and small varices) (κâ=â0.58). CONCLUSIONS: Experts working in different centres show a fairly good agreement on endoscopic features of PH in children, although a better training of paediatric endoscopists may improve the agreement in grading severity of varices in this setting.
Subject(s)
Endoscopy , Esophageal and Gastric Varices/classification , Esophageal and Gastric Varices/pathology , Adolescent , Child , Child, Preschool , Endoscopy/education , Endoscopy/statistics & numerical data , Esophageal and Gastric Varices/complications , Female , Humans , Hypertension, Portal/complications , Hypertension, Portal/pathology , Male , Observer Variation , Pediatrics/education , Pediatrics/statistics & numerical data , Reproducibility of ResultsABSTRACT
INTRODUCTION: To evaluate prostate volume change during daily-adaptive prostate SBRT on 1.5 T MR-linac and to correlate it with treatment toxicity. METHODS: a series of patients affected by low-to-intermediate risk prostate cancer was treated by 5-fraction SBRT within a prospective study (Prot. n° 23748). Total dose was 35 Gy and 36.25 Gy delivered every day or on alternate days. Treatment toxicity was recorded with the following patient reported outcomes (PROMs): IPSS, ICIQ-SF, and EPIC-26. RESULTS: 254 patients were included in the analysis. Baseline median CTV volume was 55 cc (range 15.3-163.3). Mean prostate volume were 58.9 cc, and 62.7 cc at first and last fraction respectively (mean volume increase 6.4 %; p = <0.0001). We observed prostate swelling (mean 15.4 % increase) in 50 % of cases, stable volume (≤5% volume change) in 39 % of patients, and prostate shrinkage in 11 % of cases (mean 12.2 % reduction). Baseline CTV > 55 cc showed a trend towards higher CTV shrinkage (-10.5 % versus -14.5 %; p = 0.052). We found no correlation between CTV change and PROMs. Prostate swelling was generally compensated by the planned PTV expansion, even though the mean setup volume dropped from 47.4 cc to 38.9 cc at last fraction, with few cases not covered by initial setup margins. CONCLUSION: The present study reported a significant prostate volume change during prostate SBRT on 1.5T MR-linac. We observed both prostate swelling in half of cases and few cases of prostate shrinkage. No correlations were found with PROMs in this population treatment with daily-adaptive strategy.
Subject(s)
Prostatic Neoplasms , Radiosurgery , Male , Humans , Radiosurgery/adverse effects , Prostatic Neoplasms/radiotherapy , Prostatic Neoplasms/surgery , Prostate , Prospective Studies , Pelvis , Radiotherapy Planning, Computer-AssistedABSTRACT
Aims: Evaluate effectiveness and safety of multiple HyperArc courses and patterns of progression in patients affected by BMs with intracranial progression. Methods: 56 patients were treated for 702 BMs with 197 (range 2-8) HyperArc courses in case of exclusive intracranial progression. Primary end-point was the overall survival (OS), secondary end-points were intracranial progression-free survival (iPFS), toxicity, local control (LC), neurological death (ND), and whole-brain RT (WBRT)-free survival. Site of progression was evaluated against isodoses levels (0, 1, 2, 3, 5, 7, 8, 10, 13, 15, 20, and 24 Gy.). Results: The 1-year OS was 70 %, and the median was 20.8 months (17-36). At the univariate analysis (UVA) biological equivalent dose (BED) > 51.3 Gy and non-melanoma histology significantly correlated with OS. The median time to iPFS was 4.9 months, and the 1-year iPFS was 15 %. Globally, 538 new BMs occurred after the first HA cycle in patients with extracranial disease controlled. 96.4 % of them occurred within the isodoses range 0-7 Gy as follows: 26.6 % (0 Gy), 16.5 % (1 Gy), 16.5 % (2 Gy), 20.1 % (3 Gy), 13.1 % (5 Gy), 3.4 % (7 Gy) (p = 0.00). Radionecrosis occurred in 2 metastases (0.28 %). No clinical toxicity of grade 3 or higher occurred during follow-up. One- and 2-year LC was 90 % and 79 %, respectively. At the UVA BED > 70 Gy and non-melanoma histology were significant predictors of higher LC. The 2-year WBRT-free survival was 70 %. After a median follow-up of 17.4 months, 12 patients deceased by ND. Conclusion: Intracranical relapses can be safely and effectively treated with repeated HyperArc, with the aim to postpone or avoid WBRT. Diffuse dose by volumetric RT might reduce microscopic disease also at relatively low levels, potentially acting as a virtual CTV. Neurological death is not the most common cause of death in this population, which highlights the impact of extracranial disease on overall survival.
ABSTRACT
PURPOSE: Surgical decompression is the traditional treatment for acute colorectal cancer obstruction. In recent years, colorectal stenting has been used to relieve the obstruction. This study used meta-analytic techniques to compare colonic stenting versus surgical decompression for colorectal cancer obstruction. METHODS: A comprehensive search of several databases was conducted. The search identified 321 potential abstracts and titles of which eight randomized trials involving 353 patients were retrieved in full text. A meta-analysis of the studies included was carried out to identify the differences in outcomes between the two procedures. RESULTS: The pooled analysis showed no significant differences for mortality (odds ratio (OR) 0.91) and morbidity (OR 2.05) rates between the two strategies while the permanent stoma creation rate was significantly higher in the surgical group as compared to the stent group (OR 3.12). By comparing surgery and colonic stenting in studies which analyzed the use of stenting as a "bridge to surgery," the pooled analysis showed that primary anastomosis was more frequent in the stent group as compared to the surgical group (OR 0.42), and the stoma creation was more frequent in the surgical group as compared to the stent group (OR 2.36). CONCLUSION: Our study suggested that, in patients with acute colorectal cancer obstruction, stent placement improved several outcomes, such as primary anastomosis, stoma formation, and permanent stoma, while it failed to show an improvement in mortality and morbidity risk.
Subject(s)
Colorectal Neoplasms/surgery , Decompression, Surgical/methods , Endoscopy , Intestinal Obstruction/etiology , Intestinal Obstruction/surgery , Randomized Controlled Trials as Topic , Stents , Anastomosis, Surgical , Colorectal Neoplasms/complications , Colorectal Neoplasms/mortality , Humans , Surgical StomasABSTRACT
BACKGROUND: The management of extrahepatic portal vein obstruction (EHPVO) in children is controversial. We report our experience with a prospective evaluation of a stepwise protocol based on severity of portal hypertension and feasibility of mesoportal bypass (MPB). METHODS: After diagnosis, children with EHPVO underwent surveillance endoscopies and received nonselective ß-blockers (NSBBs) or endoscopic variceal obliteration (EVO) when large varices were detected. In patients who failed NSBBs and EVO, we considered MPB as first-line and shunts or transjugular intrahepatic portosystemic shunt (TIPS) as second-line options. RESULTS: Sixty-five children, median age 12.5 (range 1.6-25.8), whose age at diagnosis was 3.5 (0.2-17.5) years, were referred to our unit. Forty-three (66%) had a neonatal illness, 36 (55%) an umbilical vein catheterisation. Thirty-two (49%) presented with bleeding at a median age of 3.8 years (0.5-15.5); during an 8.4-year follow-up period (1-16), 43 (66%) had a bleeding episode, 52 (80%) were started on NSBBs, 55 (85%) required EVO, and 33 (51%) required surgery or TIPS. The Rex recessus was patent in 24 of 54 (44%), negatively affected by a history of umbilical catheterisation (P = 0.01). Thirty-four (53%) patients underwent a major procedure: MPB (13), proximal splenorenal (13), distal splenorenal (2), mesocaval shunt (3), TIPS (2), and OLT (1). At the last follow-up, 2 patients died, 53 of 57 (93%) are alive with bleeding control, 27 of 33 (82%) have a patent conduit. CONCLUSIONS: Children with EHPVO have a high rate of bleeding episodes early in life. A stepwise approach comprising of medical, endoscopic, and surgical options provided excellent survival and bleeding control in this population.
Subject(s)
Hepatic Veno-Occlusive Disease/surgery , Portal Vein/surgery , Portasystemic Shunt, Surgical , Ablation Techniques , Adolescent , Adrenergic beta-Antagonists/therapeutic use , Adult , Child , Child, Preschool , Cohort Studies , Combined Modality Therapy , Decision Trees , Endoscopy , Follow-Up Studies , Hepatic Veno-Occlusive Disease/drug therapy , Hepatic Veno-Occlusive Disease/physiopathology , Humans , Hypertension, Portal/etiology , Hypertension, Portal/prevention & control , Infant , Italy , Retrospective Studies , Severity of Illness Index , Varicose Veins/etiology , Young AdultABSTRACT
BACKGROUND AND PURPOSE: Stereotactic body radiotherapy (SBRT) has a consolidated role in the treatment of bone oligometastases from prostate cancer (PCa). While the evidence for spinal oligometastases SBRT was robust, its role in non-spinal-bone metastases (NSBM) is not standardized. In fact, there was no clear consensus about dose and target definition in this setting. The aim of our study was to evaluate efficacy, toxicity, and the pattern of relapse in SBRT delivered to NSBM from PCa. MATERIALS AND METHODS: From 2016 to 2021, we treated a series of oligo-NSBM from PCa with 68Ga-PSMA PET/CT-guided SBRT. The primary endpoint was local progression-free survival (LPFS). The secondary endpoints were toxicity, the pattern of intraosseous relapse, distant progression-free survival (DPFS), polimetastases-free survival (PMFS), and overall survival (OS). RESULTS: a total of 150 NSBM in 95 patients were treated with 30-35 Gy in five fractions. With a median follow-up of 26 months, 1- and 3 years LPFS was 96.3% and 89%, respectively. A biologically effective dose (BED) ≥ 198 Gy was correlated with improved LPFS (p = 0.007). Intraosseous relapse occurred in eight (5.3%) cases. Oligorecurrent disease was associated with a better PMFS compared to de novo oligometastatic disease (p = 0.001) and oligoprogressive patients (p = 0.007). No grade ≥ 3 toxicity occurred. CONCLUSION: SBRT is a safe and effective tool for NSBM from PCa in the oligometastatic setting. Intraosseous relapse was a relatively rare event. Predictive factors of the improved outcomes were defined.
Subject(s)
Bile Ducts/surgery , Cholangiopancreatography, Endoscopic Retrograde/statistics & numerical data , Cholestasis/surgery , Constriction, Pathologic/surgery , Liver Transplantation/adverse effects , Postoperative Complications/surgery , Bile Ducts/diagnostic imaging , Bile Ducts/pathology , Cholangiopancreatography, Endoscopic Retrograde/instrumentation , Cholangiopancreatography, Endoscopic Retrograde/methods , Cholestasis/diagnostic imaging , Cholestasis/etiology , Constriction, Pathologic/diagnostic imaging , Constriction, Pathologic/etiology , Follow-Up Studies , Hospitals, High-Volume/statistics & numerical data , Humans , Italy , Magnetic Resonance Angiography , Patient Selection , Postoperative Complications/diagnostic imaging , Postoperative Complications/etiology , Retrospective Studies , Stents , Surveys and Questionnaires , Treatment OutcomeABSTRACT
OBJECTIVES: The aim of this review was to evaluate possible common pathogenic pathways and risk factors in inflammatory bowel disease (IBD) and periodontitis. MATERIALS AND METHODS: A MEDLINE-PubMed research was conducted. RESULTS: The pathogenesis of both diseases is multi-factorial leading to a substantial defect of the mucosal barrier, deregulation of the immune response and chronic inflammation of the mucosa. Environmental factors, particularly bacteria, are key factors in the pathogenesis of both diseases. Genetic predisposition is a key factor in the IBD pathogenesis, while a clear role of genetics in the pathogenesis of periodontitis is still unclear. The immune response in IBD is mediated by T lymphocytes as a consequence of a genetic trait associated with T-cell deregulation. On the other hand, in periodontitis plasma cells and lymphocytes are the predominant cells in the chronic inflammatory lesion, with the presence of B cells being proportionally larger than T cells. CONCLUSION: IBD and periodontitis share several factors in their aetiology and pathogenesis, although they also have distinct characteristics.
Subject(s)
Bacterial Infections/microbiology , Biofilms , Host-Pathogen Interactions/physiology , Inflammatory Bowel Diseases/microbiology , Periodontitis/microbiology , B-Lymphocytes/immunology , Bacterial Infections/genetics , Bacterial Infections/immunology , Genetic Predisposition to Disease/genetics , Humans , Inflammatory Bowel Diseases/genetics , Inflammatory Bowel Diseases/immunology , Periodontitis/genetics , Periodontitis/immunology , Plasma Cells/immunology , T-Lymphocytes/immunologyABSTRACT
AIMS: To measure patients' satisfaction after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stones in a large number of unselected endoscopy units. METHODS: A prospective study using a questionnaire (Group Health Association of America-9 [GHAA-9], modified) was administered 24 h and 30 days after the procedure. Patients undergoing endoscopy for biliary stones for the first time were enrolled in a large number of endoscopy units, regardless of their size and workload. RESULTS: In all, 700 patients were enrolled in 15 units. A high proportion of patients expressed satisfaction (80%). Satisfaction was less extensive for pain control and the quality of information provided before the procedure. There were no differences in the replies to questionnaires at 24 h and 30 days. CONCLUSION: It is feasible to record patients' satisfaction and in this series most patients were very satisfied. Criticisms concerned pain control and explanations provided before the procedure.
Subject(s)
Cholangiopancreatography, Endoscopic Retrograde , Cholelithiasis/surgery , Patient Satisfaction , Aged , Aged, 80 and over , Analgesics/therapeutic use , Attitude of Health Personnel , Cholangiopancreatography, Endoscopic Retrograde/adverse effects , Cholelithiasis/diagnostic imaging , Female , Health Knowledge, Attitudes, Practice , Humans , Italy , Male , Middle Aged , Pain, Postoperative/etiology , Pain, Postoperative/prevention & control , Patient Education as Topic , Prospective Studies , Surveys and Questionnaires , Time Factors , Treatment OutcomeABSTRACT
There was estimated a higher incidence of de novo inflammatory bowel disease (IBD) after solid organ transplantation than in the general population. The onset of IBD in the organ transplant recipient population is an important clinical situation which is associated to higher morbidity and difficulty in the medical therapeutic management because of possible interaction between anti-reject therapy and IBD therapy. IBD course after liver transplantation (LT) is variable, but about one third of patients may worsen, needing an increase in medical therapy or a colectomy. Active IBD at the time of LT, discontinuation of 5-aminosalicylic acid or azathioprine at the time of LT and use of tacrolimus-based immunosuppression may be associated with an unfavorable outcome of IBD after LT. Anti-tumor necrosis factor alpha (TNFα) therapy for refractory IBD may be an effective and safe therapeutic option after LT. The little experience of the use of biological therapy in transplanted patients, with concomitant anti-rejection therapy, suggests there be a higher more careful surveillance regarding the risk of infectious diseases, autoimmune diseases, and neoplasms. An increased risk of colorectal cancer (CRC) is present also after LT in IBD patients with primary sclerosing cholangitis (PSC). An annual program of endoscopic surveillance with serial biopsies for CRC is recommended. A prophylactic colectomy in selected IBD/PSC patients with CRC risk factors could be a good management strategy in the CRC prevention, but it is used infrequently in the majority of LT centers. About 30% of patients develop multiple IBD recurrence and 20% of patients require a colectomy after renal transplantation. Like in the liver transplantation, anti-TNFα therapy could be an effective treatment in IBD patients with conventional refractory therapy after renal or heart transplantation. A large number of patients are needed to confirm the preliminary observations. Regarding the higher clinical complexity of this subgroup of IBD patients, a close multidisciplinary approach between an IBD dedicated gastroenterologist and surgeon and an organ transplantation specialist is necessary in order to have the best clinical management of IBD after transplantation.
Subject(s)
End Stage Liver Disease/complications , End Stage Liver Disease/therapy , Heart Transplantation/adverse effects , Inflammatory Bowel Diseases/therapy , Liver Transplantation/adverse effects , Azathioprine/therapeutic use , Cholangitis, Sclerosing/complications , Cholangitis, Sclerosing/therapy , Colectomy/adverse effects , Colorectal Neoplasms/complications , Colorectal Neoplasms/therapy , Graft Rejection/prevention & control , Humans , Inflammatory Bowel Diseases/complications , Kidney Transplantation/adverse effects , Mesalamine/therapeutic use , Risk Factors , Tacrolimus/therapeutic use , Treatment Outcome , Tumor Necrosis Factor-alpha/antagonists & inhibitorsABSTRACT
In 2011 the three major Italian gastroenterological scientific societies (AIGO, the Italian Society of Hospital Gastroenterologists and Endoscopists; SIED, the Italian Society of Endoscopy; SIGE, the Italian Society of Gastroenterology) prepared their official document aimed at analysing medical care for digestive diseases in Italy, on the basis of national and regional data (Health Ministry and Lombardia, Veneto, Emilia-Romagna databases) and to make proposals for planning of care. Digestive diseases were the first or second cause of hospitalizations in Italy in 1999-2009, with more than 1,500,000 admissions/year; however only 5-9% of these admissions was in specialized Gastroenterology units. Reported data show a better outcome in Gastroenterology Units than in non-specialized units: shorter average length of stay, in particular for admissions with ICD-9-CM codes proxying for emergency conditions (6.7 days versus 8.4 days); better case mix (higher average diagnosis-related groups weight in Gastroenterology Units: 1 vs 0.97 in Internal Medicine units and 0.76 in Surgery units); lower inappropriateness of admissions (16-25% versus 29-87%); lower in-hospital mortality in urgent admissions (2.2% versus 5.1%); for patients with urgent admissions due to gastrointestinnal haemorrhage, in-hospital mortality was 2.3% in Gastroenterology units versus 4.0% in others. The present document summarizes the scientific societies' official report, which constitutes the "White paper of Italian Gastroenterology".
Subject(s)
Gastroenterology/statistics & numerical data , Gastrointestinal Diseases/epidemiology , Gastrointestinal Diseases/therapy , Health Services Needs and Demand/statistics & numerical data , Health Services/statistics & numerical data , Hospital Units/statistics & numerical data , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Emergencies , Female , Gastroenterology/organization & administration , Gastrointestinal Diseases/diagnosis , Gastrointestinal Hemorrhage/mortality , Gastrointestinal Hemorrhage/therapy , Health Planning , Hospital Mortality , Humans , Incidence , Infant , Infant, Newborn , Italy/epidemiology , Length of Stay , Male , Middle Aged , Prevalence , Societies, Medical , Treatment Outcome , Young AdultABSTRACT
Optimal perioperative antiplatelet therapy in patients with coronary stents undergoing surgery still remains poorly defined and a matter of debate among cardiologists, surgeons and anaesthesiologists. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. Clinical practice guidelines provide little support with regard to managing antiplatelet therapy in the perioperative phase in the case of patients with non-deferrable surgical interventions and/or high haemorrhagic risk. Moreover, a standard definition of ischaemic and haemorrhagic risk has never been determined. Finally, recommendations shared by cardiologists, surgeons and anaesthesiologists are lacking. The present consensus document provides practical recommendations on the perioperative management of antiplatelet therapy in patients with coronary stents undergoing surgery. Cardiologists, surgeons and anaesthesiologists have contributed equally to its creation. On the basis of clinical and angiographic data, the individual thrombotic risk has been defined. All surgical interventions have been classified according to their inherent haemorrhagic risk. A consensus on the optimal antiplatelet regimen in the perioperative phase has been reached on the basis of the ischaemic and haemorrhagic risk. Aspirin should be continued perioperatively in the majority of surgical operations, whereas dual antiplatelet therapy should not be withdrawn for surgery in the case of low bleeding risk. In selected patients at high risk for both bleeding and ischaemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be taken into consideration.
Subject(s)
Hemorrhage/prevention & control , Myocardial Ischemia/prevention & control , Perioperative Care/standards , Platelet Aggregation Inhibitors/therapeutic use , Stents , Surgical Procedures, Operative/methods , Anesthesiology , Aspirin/therapeutic use , Cardiac Surgical Procedures/methods , Cardiology , Clopidogrel , Eptifibatide , Humans , Italy , Peptides/therapeutic use , Platelet Glycoprotein GPIIb-IIIa Complex/antagonists & inhibitors , Risk Assessment , Societies, Medical , Thoracic Surgery , Ticlopidine/analogs & derivatives , Ticlopidine/therapeutic use , Tirofiban , Tyrosine/analogs & derivatives , Tyrosine/therapeutic useSubject(s)
Churg-Strauss Syndrome/diagnosis , Duodenum/pathology , Intestine, Small/diagnostic imaging , Mesentery/diagnostic imaging , Rare Diseases , Anorexia/etiology , Churg-Strauss Syndrome/complications , Diarrhea/etiology , Endoscopy, Digestive System , Humans , Male , Middle Aged , Nausea/etiology , Ultrasonography , Weight LossABSTRACT
BACKGROUND: Self-expanding metal stents (SEMSs) are used to treat malignant stenosis of the gastrointestinal (GI) tract, as a safe, feasible, and minimally invasive option for reestablishing luminal patency. However, the literature offers scant prospective data on the clinical outcome of these patients. AIM: To assess the technical success, complications, and clinical outcomes of patients with a SEMS placed for malignant upper and lower GI obstruction. PATIENTS AND METHODS: A cohort of 110 patients with clinical symptoms related to malignant stenosis of the upper and lower GI tract were prospectively enrolled and SEMSs were placed endoscopically in 9 endoscopy centers. The patients were followed up and survival, oral intake, stool canalization, and late complications were recorded on days 30, 90, and 180. RESULTS: Overall, 110 patients, 38 (34.5%) with upper and 72 (65.5%) with lower GI obstruction were examined. The procedure was successful in 102 (92.7%). There were 5 early complications (<96 h) (4.5%). Late complications (>96 h) occurred in 6 patients (6.3%). Median survival after stenting was 90 days (q1 30; q3 120). Placing the SEMS enabled 79.4%, 90.9%, and 100% of the patients to resume an oral diet at 30, 90, and 180 days, respectively. All patients had stool canalization until death. CONCLUSIONS: Endoscopic stenting is an effective and safe procedure for malignant luminal obstruction of the GI tract, with good clinical outcomes in patients whose survival is unfortunately short.