Outcomes of endoscopic full thickness resection in the colon rectum at an Italian tertiary center.

PURPOSE: Endoscopic full-thickness resection (EFTR) is an innovative technique for the treatment of colonic lesions not feasible by conventional endoscopic resection. Here, we aimed to evaluate the efficacy and safety of a Full-Thickness Resection Device (FTRD) for colonic lesions in a high-volume tertiary referral center. METHODS: A review of a prospectively collected database on patients that underwent EFTR with FTRD for colonic lesions from June 2016 to January 2021 at our institution was performed. Data regarding the clinical history, previous endoscopic treatments, pathological examination, technical and histological success, and follow-up were evaluated. RESULTS: Thirty-five patients (26 males, median age 69 years) underwent FTRD for colonic lesion. Eighteen lesions were in the left colon, three in the transverse, and 12 in the right colon. The median size of the lesions was 13 (range 10-40) mm. Resection was technically successful in 94% of patients. The mean hospital stay was 3.2 (SD ± 1.2) days. Adverse events were reported in four cases (11.4%). Histological complete resection (R0) was achieved in 93.9% of cases. Endoscopic follow-up was available in 96.8% of patients, at a median duration of 14.6 months (3-46 months). Recurrence was observed in 19.4% of cases at a median time of 3 months (3-7 months). Five patients had multiple FTRD performed, with R0 resection in three cases. In this subset, adverse events were observed in 40% of cases. CONCLUSIONS: FTRD is safe and feasible for standard indication. The non-negligible rate of recurrence observed suggests the need for close endoscopic follow-up in these patients. Multiple EFTR could help achieve complete resection in selected cases; however, in this setting, a higher risk of adverse events was observed.

Downward Neighborhood Poverty Mobility during Childhood Is Associated with Child Asthma: Evidence from the Geographic Research on Wellbeing (GROW) Survey.

Causal evidence regarding neighborhood effects on health remains tenuous. Given that children have little agency in deciding where they live and spend proportionally more of their lives in neighborhoods than adults, their exposure to neighborhood conditions could make their health particularly sensitive to neighborhood effects. In this paper, we examine the relationship between exposure to poor neighborhoods from birth to ages 4-10 and childhood asthma. We used data from the 2003-2007 California Maternal Infant and Health Assessment (MIHA) and the 2012-2013 Geographic Research on Wellbeing (GROW) survey (N = 2619 mother/child dyads) to fit relative risks of asthma for children who experience different types of neighborhood poverty mobility using Poisson regression controlling for individual-level demographic and socioeconomic characteristics, and neighborhood satisfaction. Our results demonstrate that [1] living in a poor neighborhood at baseline and follow-up and [2] moving into a poor neighborhood were each associated with higher risk of asthma, compared with children not living in a poor neighborhood at either time. Exposure to impoverished neighborhoods and downward neighborhood poverty mobility matters for children's health, particularly for asthma. Public health practitioners and policymakers need to address downward neighborhood economic mobility, in addition to downward family economic mobility, in order to improve children's health.

Liver Transplantations and Brain Dead Donors With Alcohol Abuse.

BACKGROUND AND AIM: Liver grafts from donors with chronic and active history of alcohol abuse are usually immediately ruled out for use in liver transplantation (LT). The aim of our study is to evaluate the use of those grafts. METHODS: From 2011 to 2016, a study group (Group 1) composed of 5 adult LT patients transplanted with livers from donors with alcohol abuse, was compared with a control group (Group 2) of 10 randomly matched patients who received liver transplants. Preoperative, intraoperative, and postoperative data were compared. RESULTS: Among donors, serum gamma-glutamyl transferase values were significantly higher in Group 1. In recipients, post-LT laboratory exams showed significantly higher peak values of aspartate transaminase and alanine transaminase in Group 1; higher values of aspartate aminotransferase, alanine aminotransferase, and total bilirubin in Group 1 were also recorded on day 0. Early allograft dysfunction occurred at higher rates in Group 1 (80% vs 20%, P = .025), with no differences in early rejection episodes or early surgical repeat interventions. All patients from both groups were alive after 20 ± 10 (range 6-35) months from LT. CONCLUSION: Despite higher rates of early allograft dysfunction, selected liver grafts from donors with alcohol abuse can be accepted for LT with good clinical results.

Traditional vs wireless intragastric pH monitoring: are the two techniques comparable?

BACKGROUND: Few data are available comparing intragastric pH measured with the traditional catheter-based and the more recent wireless system (Bravo), and also comparing intraesophageal and intragastric pH during reflux events. Aims of our study were to elucidate these points. METHODS: Eleven subjects with functional dyspepsia underwent placement of a Bravo capsule 9 cm below the squamo-columnar junction (SCJ) and of a dual-electrode catheter, so that the distal electrode was located 9 cm below and the proximal one 6 cm above the SCJ. KEY RESULTS: The wireless system showed lower intragastric pH than the traditional catheter in the postprandial period (median 2.2 wireless vs 2.7 catheter, P < 0.05) but not in the whole 24 h. Moreover, during the 24 h, minimum intraesophageal pH during reflux events was lower than the simultaneous pH in the gastric body recorded using the catheter (2.2 vs 2.4, P < 0.01) and in the postprandial period lower than the one recorded using both techniques (2.3 vs 2.8 wireless and 3.2 catheter, P < 0.001). CONCLUSIONS & INFERENCES: (i) after meals, in the 1st 2 h postprandial pH in the gastric body is significantly lower when measured with the wireless capsule than with the traditional catheter, presumably because of less buffering by food in proximity of the mucosa, (ii) during reflux events intraesophageal pH is lower than pH in the gastric body, in accordance with the notion of greater intragastric acidity in the subcardial region.

Note: high capacity digital laser beam steering system.

The combination of liquid crystal cells with polarizing cube beam splitters has been used to direct a beam of light to multiple directions. The polarization at each beam splitter is controlled by applying a signal to a corresponding liquid crystal cell. Ten cascaded stages have deflected a HeNe laser beam to 1024 digitally selectable angles.

Role of a short-term stent-trial in a patient with biliary stricture and portal hypertensive biliopathy: long-term outcome result.

In portal hypertensive biliopathy (PHB) secondary to portal thrombosis, multiple factors can lead to symptoms and alteration of liver tests. The compression of the common bile duct (CBD) by peribiliary varices, portal vein thrombus or cavernoma, or the presence of biliary stone and an associated ischemic stricture are proposed to be involved in the pathogenesis of symptoms (jaundice, abdominal pain, fever) and alterations of liver tests. We present a case of a young HCV-infected male patient in which multiple factors in PHB as mentioned above were present. Clinical and biochemical evaluations after a short-term biliary stent and after its removal (stent-trial) showed the major role of the ischemic-associated stricture and rule out other factors in our patient. Long-term data support this result.

Role of symptoms, trend of liver tests, and endotherapy in management of post-cholecystectomy biliary leak.

AIM: Biliary leaks are widely reported complications of cholecystectomy, but standard management remains undecided. The objective of our study was to report the role of symptoms, biochemical tests, and ERCP in patients with a leak. MATERIALS AND METHODS: Twenty-one patients (8 M, 26-77 years) with suspected post-cholecystectomy biliary leak were retrospectively studied. Symptoms and liver tests (LTs) after surgery were monitored. Trends of LTs were considered positive if increases at >48 h were seen. ERCP was performed in all patients. Findings at endoscopy and treatments were reported. Outcome results were obtained for all patients. RESULTS: Seventeen of 21 patients had persistent biliary leak at ERCP, because of direct injury (n = 10), accessory duct (n = 4), or cystic duct stump (n = 3). Eleven of 17 patients (six without symptoms), had distal obstruction because of surgical injury (n = 8), stone (n = 2), or cholangiocarcinoma (n = 1) and underwent stenting (n = 4), naso-biliary drainage, NBD (n = 3), or surgery (n = 4). Among the six patients without obstruction (four without symptoms), stenting was performed in two and NBD in four. The four patients without apparent leak underwent NBD. Impairment of LTs was present in ten out of eleven (91%) patients with obstruction versus six of ten (60%) without obstruction. No complications occurred after ERCP. During a median follow-up of 33 months (cholangiocarcinoma excluded) all but one remained asymptomatic. CONCLUSIONS: Symptoms and trend of LTs were not predictive of biliary obstruction in patients with a leak after cholecystectomy. Both endotherapy and surgery had favorable outcomes.

A pneumatic dilation strategy in achalasia: prospective outcome and effects on oesophageal motor function in the long term.

BACKGROUND: Long-term follow-up studies of achalasia after pneumatic dilation, mostly retrospective, have shown variable results. AIM: To examine the outcome of achalasia after pneumatic dilation using a prospective follow-up programme. METHODS: One or two dilations (first dilation treatment) in 77 patients to achieve stable (>1 year) remission and patients followed up with yearly clinical and manometric assessments. Endoscopy, pH monitoring and barium swallow were also performed. RESULTS: A total of 69 patients achieved stable remission and were followed up for 5.6 years (3-10.7) [median (IQ range)], whereas six patients underwent cardiomyotomy and two experienced a perforation. Twelve of the 69 patients relapsed after 2.6 years (1.7-5.1): nine of 12 underwent one to two further dilations. Six-year remission rate (by Kaplan-Meyer estimates) was 82% after first dilation treatment and 96% after all dilations. Continuous antisecretory treatment was clinically needed in 16%, oesophagitis present in 7% and reflux pathological in 28% of the patients. Beneficial effects of dilation on oesophageal motility and on diameter of the oesophageal body at barium swallow were maintained during follow-up. CONCLUSIONS: A management strategy including sessions of pneumatic dilation until stable remission and a standardized follow-up is highly successful in the long term. Gastro-oesophageal reflux is clinically relevant in a minority of patients.

ERCP and short-term stent-trial in patients with anastomotic biliary stricture following liver transplantation.

BACKGROUND: Anastomotic biliary stricture represents one of the possible factors leading to liver dysfunction after transplantation. PURPOSE: Our aims were to evaluate the role of endoscopic retrograde cholangio-pancreatography and a short-term stenting (stent-trial) in assessment of the clinical relevance of the biliary stricture. MATERIALS AND METHODS: Thirty transplanted patients for HCV (n=17) or non-HCV (n=13)-related cirrhosis (27M, median age 53 yr, range 24-67 yr) who developed persistently abnormal liver function tests and presented with an anastomotic biliary stricture suggested by non-invasive cholangiography, underwent endoscopic retrograde cholangio-pancreatography. If the stricture was confirmed, dilation was performed and a plastic stent was placed. Clinical and biochemical evaluation was done one and two months later. Resolution of symptoms and normalization or > 50% reduction of at least one liver function test were needed to consider the stricture as clinically relevant. Patients were followed up for a median of 19 months. RESULTS: Endoscopic retrograde cholangio-pancreatography was successful in 29 patients and confirmed the anastomotic biliary stricture in 19 (66%); 14 patients underwent endoscopic dilation and stenting and five patients underwent surgery. The stent-trial suggested the stricture to be clinically relevant in 7 of 14 patients, confirmed by prolonged stenting and follow-up. A trend towards a higher likelihood of a clinically relevant stricture was observed in HCV-negative compared to HCV-positive patients (5 of 7, 71% vs 2 of 7, 29% , respectively; p=0.1). CONCLUSIONS: Our data suggest that endoscopic retrograde cholangio-pancreatography is a valuable tool to evaluate the clinical relevance of an anastomotic stricture, when coupled with a short-term stent-trial.

Cardiovascular effects of gastric intubation and distension in healthy humans.

Few data exist on the effect of upper gut stimuli on the cardiovascular system. Aim of our study was to evaluate the cardiovascular effects of gastric intubation and distension. Eleven healthy subjects (eight men, aged 21-30 years) were studied and a non-invasive beat-to-beat cardiovascular monitoring system was used. After 15-min basal recording, a bag catheter was positioned in the proximal stomach and connected to a barostat. Recordings were first performed for 15 min with the bag deflated, then during inflation of air using a 100 mL per 2 min stepwise protocol until epigastric discomfort was reported, and finally for 15 min with the bag inflated at 75% of discomfort volume spared from the preceding period by 10 min with the bag deflated. Presence of the deflated bag catheter significantly increased mean arterial pressure. Stepwise distension progressively increased heart rate and cardiac index, while mean arterial pressure was affected only at discomfort volume. Peripheral resistances and systemic plasma catecholamines were unaffected. During prolonged distension, the effect on heart rate and cardiac index was transient. In conclusion, both gastric intubation and distension alter cardiovascular parameters, but the effect of distension undergoes rapid adaptation. Experimentally induced gastric distension is a valuable stimulus to study viscero-cardiovascular reflexes and their mechanisms using beat-to-beat measurements.

Wireless pH monitoring: better tolerability and lower impact on daily habits.

BACKGROUND: Twenty-four hours oesophageal pH monitoring is considered the reference-standard for the diagnosis of gastro-oesophageal reflux disease, but it is limited by catheter discomfort and limitations of daily habits. AIM: We evaluated tolerability and impact on food intake and daily activities of catheter-based compared to wireless pH monitoring. PATIENTS: One-hundred and thirty-three consecutive patients with suspected gastro-oesophageal reflux disease were enrolled. METHODS: Seventy-eight patients (36 M, 53+/-2 years) underwent the 24 h catheter-based and 55 patients (25 M, 44+/-3 years) the 48 h wireless pH monitoring. Discomfort at placement and during the test was evaluated by 100 mm visual analogue scales. Limitations of food intake and of daily activities were evaluated by standardized questionnaires (score 0 to 3). RESULTS: Discomfort (mean+/-standard error of the mean) at placement and during the test was 32+/-3 versus 29+/-4 (p=ns) and 37+/-3 versus 22+/-3 (p<0.001) for the catheter-based versus wireless techniques. Limitation of food intake and of daily activities (mean+/-standard error of the mean) were 0.9+/-0.1 versus 0.4+/-0.1 (p<0.05) and 1.2+/-0.1 versus 0.2+/-0.1 (p<0.0001), respectively. CONCLUSIONS: The wireless pH monitoring is better tolerated and has minor impact on daily habits compared to the traditional technique. Whether this translates into better diagnostic accuracy remains to be evaluated.

Multiple rapid swallowing in idiopathic achalasia: evidence for patients' heterogeneity.

In order to evaluate the function of inhibitory neural pathways in achalasia, we compared the response of the oesophageal body and lower oesophageal sphincter (LOS) to single swallows (SS) and multiple rapid swallowing (MRS) in 20 consecutive patients with untreated idiopathic achalasia (10 men, aged 23-81 years) and in 20 control patients without dysphagia (nine men, aged 31-73 years), using sleeve manometry; 277 SS and 85 MRS were analysed. In the control group, MRS inhibited motor activity in the oesophageal body and induced a slightly lower (P < 0.05) nadir LOS pressure compared with SS. In the achalasia patients, MRS induced a variable response: eight patients had simultaneous motor activity during all MRS although onset was delayed compared with SS [median (interquartile range), 3.5 s (1.7-6.1) vs 1.4 s (0.8-3.9); P < 0.05], whereas eight patients showed motor inhibition which occurred during all MRS in four of them, and the remaining four had no motor activity both after SS and during MRS. Overall MRS did not decrease nadir LOS pressure compared with SS [12 mmHg (5-20) vs 16 mmHg (7-22); P > 0.1]; however, it induced complete LOS relaxation in three of the patients. MRS gives further evidence of functional heterogeneity among achalasia patients.

The treatment of patients with symptomatic common bile duct stenosis secondary to chronic pancreatitis using partially covered metal stents: a pilot study.

BACKGROUND AND STUDY AIMS: Although surgery remains the gold standard for the treatment of symptomatic common bile duct stenosis associated with chronic pancreatitis, plastic and self-expandable open-mesh stents have been proposed as alternative treatments. These may dysfunction, however, mainly due to stent occlusion by clogging or by hyperplasia of inflammatory tissue. The aim of this study was to evaluate the safety and long-term results of using partially covered metal stents in this setting. PATIENTS AND METHODS: A total of 14 patients (12 men, 2 women; mean age 50 +/- 3 years) underwent partially covered metal stent insertion for common bile duct stenosis secondary to chronic pancreatitis (12 alcohol-related, two idiopathic). They had all been treated previously with plastic prostheses. RESULTS: Either a 40-mm (n = 13) or a 60-mm (n = 1) partially covered metal stent was placed, depending on the length of the common bile duct stenosis and the level of the cystic duct bifurcation. Stent placement was successful, with resolution of cholangitis and improvement in cholestasis, in all patients. During the median follow-up period of 22 months (range 12 - 33 months) seven patients developed dysfunction of the stent and required re-treatment. At 12, 24, and 30 months, the stent patency rates were 100 %, 40 %, and 37.5 % respectively. CONCLUSIONS: While partially covered metal stenting is safe and effective for the initial treatment of chronic pancreatitis-associated common bile duct stenosis and shows promising short-term results, long-term data show that dysfunction occurs in 50 % of cases. In light of the continued interest in nonsurgical treatment of this condition, further research is warranted to investigate new stent designs with improved long-term patency.

Impact of referral for gastro-oesophageal reflux disease on the workload of an academic Gastroenterology Unit.

BACKGROUND: Gastro-oesophageal reflux disease is known to be a frequent cause of patients' referral to hospital gastroenterologists. AIM: To increase knowledge on referral for reflux disease, in an Italian academic setting. PATIENTS AND METHODS: The impact of gastro-oesophageal reflux disease on 1 year's workload, comprising upper endoscopy, outpatients' consultations in the general clinic, oesophageal pH monitoring and oesophageal manometry was retrospectively assessed. Appropriateness of oesophageal pH monitoring and oesophageal manometry was also evaluated. RESULTS: Endoscopy: Out of 2269 upper endoscopies reflux symptoms comprised 16.9% (n=386) of referrals; 19.1% only of these 386 patients had erosive oesophagitis at endoscopy and none had oesophagogastric malignancies (68% of the patients were >45 years). Consultations: Thirty-three percent out of 553 patients were referred for reflux symptoms. Upper endoscopy had already been performed before consultation in 64% of them. pH monitoring and oesophageal manometry: Two hundred and sixteen oesophageal pH monitorings and 160 oesophageal manometries were performed and 29% and 28%, respectively, were inappropriate, being performed in the diagnostic work-up of patients with typical reflux symptoms. CONCLUSIONS: At an academic Gastroenterology Unit, (a) gastro-oesophageal reflux disease is a frequent referral for upper endoscopy and consultations, (b) prevalence of oesophagitis is low, (c) consultation is preceded by endoscopy in the majority of patients and (d) oesophageal pH monitoring and oesophageal manometry are often inappropriately used.

Ringed oesophagus and idiopathic eosinophilic oesophagitis in adults: an association in two cases.

Ringed oesophagus is an increasingly recognised finding in young people presenting with dysphagia and may be related to eosinophilic oesophagitis. Recently, hypotheses regarding potential aetiologies have been proposed but these have not been systemically tested in the majority of reported cases. We report two cases very similar in clinical history and endoscopic findings. An association with gastro-oesophageal reflux disease or motility abnormalities of the oesophagus were ruled out in both. Histological analysis revealed high-density infiltration of the oesophageal mucosa by eosinophils and excluded gastro-duodenal involvement. Examinations of the oesophagus at the time of low frequency dysphagia, some years before presentation to our centre, did not show rings, suggesting that multiple rings are a possible late complication of eosinophilic oesophagitis. Oesophageal dilatation effectively relieved dysphagia in our two patients.

Relationship between motor function of the proximal stomach and transient lower oesophageal sphincter relaxation after morphine.

BACKGROUND: Morphine reduces the rate of transient lower oesophageal sphincter (LOS) relaxations but its site of action is presently unknown. There are no data available concerning its motor effects on the proximal stomach, an important site for triggering transient LOS relaxations. AIM: To evaluate the effect of morphine on the rate of transient LOS relaxations and motor function of the proximal stomach. SUBJECTS AND METHODS: In 19 healthy subjects, concurrent transient LOS relaxations with a sleeve sensor and motor function of the proximal stomach with a bag connected to an electronic barostat were recorded during pressure controlled (n = 9) and volume controlled (n = 10) gastric distensions after intravenous administration of placebo and morphine 100 microg/kg. RESULTS: During pressure controlled distensions, intrabag volume was markedly decreased by morphine (median 189 ml (interquartile range 101-448) v 404 (265-868) after placebo; p<0.01) as was the rate of transient LOS relaxations (0.5/30 minutes (0.4-2) v 2.5 (2-4); p<0.01). When intrabag volume was kept constant (525 ml (490-600)) (that is, in volume controlled distensions), the rate of transient LOS relaxations was not affected by morphine (2/30 minutes (2-3) v 2.5 (2-3)). Gastric contractions decreased after morphine similarly during pressure controlled and volume controlled distensions (8.5/30 minutes (4-10) v 15.5 (9.5-20.5), p<0.02; and 6.5 (0-24) v 19.5 (12-22), p<0.05). CONCLUSIONS: The effect of morphine on transient LOS relaxations is dependent on the decrease in volume of the proximal stomach. Our data suggest that pharmacological interventions which decrease fundal volume should result in control of transient LOS relaxation mediated gastro-oesophageal reflux.