Anal defecatory function in ulcerative colitis patients after total proctocolectomy and ileal pouch-anal anastomosis: a prospective cohort study.

BACKGROUND: Total proctocolectomy (TPC) followed by ileal pouch-anal anastomosis (IPAA) remains the only viable option whenever different treatment modalities fail in patients with ulcerative colitis (UC). OBJECTIVE: Prospective cohort pre/post study examining the anal defecatory function and competence in UC patients undergoing TPC plus IPAA using high-resolution anorectal manometry (HR-ARM). PATIENTS: Patients undergoing TPC and IPAA were enrolled in the study and subjected to HR-ARM prior to and 6 months after surgery. The anal resting, squeeze and push pressures were recorded, together with the rectal sensation and the rectal balloon expulsion test. The number of bowel movements, symptoms/signs related to fecal incontinence, as well as the IBDQ-32 quality of life questionnaires were documented during both HR-ARM visits. RESULTS: A total of 20 consecutive UC patients were recruited in our study. The mean (SD) number of bowel movements before the TPC plus IPAA was 10.1 (2.8), while the same number after the pouch surgery was 7.7 (3.1) [ P  = 0.01]. Symptoms or signs of fecal incontinence were noted in one of our patients prior to the operation; however, none of our patients reported any such symptoms after the pouch surgery. The median (IQR) IBDQ-32 questionnaire scores before and after surgery were 121.5 (13.5) and 142.5 (16.0) respectively. At the same time, the anorectal function remained intact since both the anal resting and squeeze pressures were not significantly changed. CONCLUSION: UC patients subjected to TPC-IPAA exhibit improved bowel movements and a normal anal defecatory function and competence post-surgery.

Sedation during endoscopic procedures: a Hellenic Society of Gastroenterology Position Statement.

Administration of sedation by non-anesthesiologists during gastrointestinal endoscopy remains highly controversial in Greece. The aim of this set of 16 position statements prepared by experts in the field on behalf of the Hellenic Society of Gastroenterology is to aid gastroenterologists in their everyday clinical practice and provide evidence for the best use of drugs for the sedation of patients who undergo an endoscopy. The statements address issues such as the level of sedation required, the best drugs used, their mode of action, their side-effects and possible ways to counter their action, and were adopted if at least 80% of all participants agreed upon them.

Efficacy and safety of transpancreatic sphincterotomy in endoscopic retrograde cholangiopancreatography: a retrospective cohort study.

Background: Difficult cannulation represents a common obstacle during endoscopic retrograde cholangiopancreatography (ERCP). We assessed the efficacy and adverse events of transpancreatic sphincterotomy (TPS), and investigated potential associated confounders. Methods: All patients referred to our department for ERCP during 2015-2020 were eligible if they had intact papilla and visceral anatomy. In addition to standard measures, TPS was combined with pancreatic stent placement. Apart from demographics, we retrieved data related to the indication, periampullary anatomy, necessity for TPS or fistulotomy, their outcomes and complications. Chi-square test was employed to investigate associations between TPS and independent variables. When significance was observed, the respective variables were inserted into a regression model. Results: A total of 1082 individual patients were eligible, with an equal female: male ratio and a mean age of 72.7±15.82 years. Seventy-three patients (6.7%) underwent TPS, with a 95.9% successful cannulation rate. Papilla morphology or regional diverticulum did not affect the decision to perform TPS, though it was significantly associated with malignant common bile duct (CBD) obstruction as the ERCP indication (P=0.001). Considering adverse events, TPS did not increase the incidence of post-ERCP pancreatitis (PEP), though it affected bleeding (P=0.005). Regression analysis revealed a protective role of TPS against PEP (risk ratio [RR] 0.015, 95% confidence interval [CI] 0.23-5.05; P<0.001), while the aforementioned risk of hemorrhage was attributed to previous precut attempts (RR 3.02, 95%CI 1.42-6.43; P=0.004). Conclusion: TPS combined with pancreatic stenting is an effective and safe modality in difficult cannulation cases and could be the first-choice alternative in malignant CBD obstruction.

State of the Art in Endoscopic Therapy for the Management of Gastroenteropancreatic Neuroendocrine Tumors.

OPINION STATEMENT: Gastroenteropancreatic neuroendocrine neoplasms (GEP NENs) comprise a heterogeneous group of slow growing tumors arising from the neuroendocrine cells of the gastrointestinal (GI) tract. Although they are considered relatively rare, their incidence is rising and it is believed that the more frequent use of endoscopy and imaging studies have at least in part contributed to the increased diagnosis especially of localized neoplasms. The management of these neoplasms should be guided by a multidisciplinary NEN team following appropriate staging investigations. Localized neoplasms of the GI tract may be suitable for endoscopic therapy, while patients with pancreatic NENs, unsuitable for surgery, should be considered for endoscopic ultrasound (EUS)-guided ablation. In this review, we discuss the evidence regarding endoscopic resection of luminal NENs and EUS-guided therapy of pancreatic NENs. The efficacy, safety, and other longer-term outcomes of these techniques are summarized. In conclusion, this review of endoscopic therapies for localized NENs may be a useful guide for NEN clinicians and endoscopists who are considering these therapeutic options for the management of focal GEP NENs.

Role of autophagy in gastric carcinogenesis.

Gastric cancer represents a common and highly fatal malignancy, and thus a pathophysiology-based reconsideration is necessary, given the absence of efficient therapeutic regimens. In this regard, emerging data reveal a significant role of autophagy in gastric oncogenesis, progression, metastasis and chemoresistance. Although autophagy comprises a normal primordial process, ensuring cellular homeostasis under energy depletion and stress conditions, alterations at any stage of the complex regulatory system could stimulate a tumorigenic and promoting cascade. Among others, Helicobacter pylori infection induces a variety of signaling molecules modifying autophagy, during acute infection or after chronic autophagy degeneration. Subsequently, defective autophagy allows malignant transformation and upon cancer establishment, an overactive autophagy is stimulated. This overexpressed autophagy provides energy supplies and resistance mechanisms to gastric cancer cells against hosts defenses and anticancer treatment. This review interprets the implicated autophagic pathways in normal cells and in gastric cancer to illuminate the potential preventive, therapeutic and prognostic benefits of understanding and intervening autophagy.

Ulcerative Colitis in Hematological Malignancies: Paraneoplastic Manifestation or Coincidental Bystander?

Evidence of coexistence of diverse hematological malignancies-lymphoma, leukemia, multiple myeloma, and myelodysplastic syndromes-and either ulcerative colitis or Crohn's disease can be found in the literature. However, a more "systemic" effort to reach further and examine the potential of either one as paraneoplastic manifestation has not been performed. Based on these, three cases of ulcerative colitis manifesting before, simultaneously, and after the onset of different hematological malignancies are presented and critically evaluated.

Liver cirrhosis-effect on QT interval and cardiac autonomic nervous system activity.

AIM: To examine the impact of liver cirrhosis on QT interval and cardiac autonomic neuropathy (CAN). METHODS: A total of 51 patients with cirrhosis and 51 controls were examined. Standard 12-lead electrocardiogram recordings were obtained and QT as well as corrected QT interval (QTc) and their dispersions (dQT, dQTc) were measured and calculated using a computer-based program. The diagnosis of CAN was based upon the battery of the tests proposed by Ewing and Clarke and the consensus statements of the American Diabetes Association. CAN was diagnosed when two out of the four classical Ewing tests were abnormal. RESULTS: QT, QTc and their dispersions were significantly longer (P < 0.01) in patients with cirrhosis than in controls. No significant differences in QT interval were found among the subgroups according to the etiology of cirrhosis. Multivariate regression analysis after controlling for age, gender and duration of cirrhosis demonstrated significant association between QT and presence of diabetes mellitus [standardized regression coefficient (beta) = 0.45, P = 0.02] and treatment with diuretics (beta = 0.55, P = 0.03), but not with the Child-Pugh score (P = 0.54). Prevalence of CAN was common (54.9%) among patients with cirrhosis and its severity was associated with the Child-Pugh score (r = 0.33, P = 0.02). Moreover, patients with decompensated cirrhosis had more severe CAN that those with compensated cirrhosis (P = 0.03). No significant association was found between severity of CAN and QT interval duration. CONCLUSION: Patients with cirrhosis have QT prolongation. Treatment with diuretics is associated with longer QT. CAN is common in patients with cirrhosis and its severity is associated with severity of the disease.

Laparoendoscopic rendezvous may be an effective alternative to a failed preoperative endoscopic retrograde cholangiopancreatography in patients with cholecystocholedocholithiasis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP), followed by laparoscopic cholecystectomy (LC), remains the standard way of management for patients with cholecystocholedocholithiasis. Laparoendoscopic rendezvous (LERV), a combined procedure for removing the gallbladder laparoscopically and clearing the common bile duct (CBD) endoscopically at the same time, could be an attractive alternative. The aim of this study was to compare LERV with classic ERCP in patients with cholecystocholedocholithiasis. METHODS: 886 patients with cholecystocholedocholithiasis were treated either with the LERV technique (90 patients), or with the 2-stage approach, which includes preoperative ERCP followed by LC (796 patients). The primary endpoint was any difference in the success of CBD cannulation and clearance; secondary endpoints were the detection of differences in morbidity (especially post-ERCP pancreatitis [PEP]), and the feasibility of the two approaches. RESULTS: Successful cannulation of the CBD was more frequent with conventional ERCP compared with the LERV technique (89.8% vs. 75.5%, P=0.0001). LERV appears to be as effective as conventional ERCP for complete CBD clearance (85.5% vs. 82.8%, P<0.1). None of the patients in the LERV group had an episode of clinical PEP, whereas in the conventional ERCP group there were 23 episodes of PEP and one death. The median amylase level was higher in patients undergoing conventional ERCP group compared to patients in LERV group. CONCLUSION: Classic ERCP has a higher rate of successful CBD cannulation and a similar rate of CBD clearance compared to LERV.

Acute appendicitis in a duplicated appendix.

INTRODUCTION: Double appendix represents an extremely rare and commonly "missed" diagnosis, often with life threatening consequences. PRESENTATION OF CASE: In this case report we present an interesting case of operative treatment of acute appendicitis in a doubled vermiform appendix stemming operative pitfalls. A 23-year-old female was admitted to the emergency room department complaining of diffuse abdominal pain, nausea, and vomiting over the past 36h. As soon as the diagnosis of acute appendicitis was established a laparotomy via a McBurney incision was decided. Intraoperative findings included the presence of mild quantity of free fluid and surprisingly a thin non-inflamed appendiceal process. It was the preoperative ultrasound findings suggestive of acute appendicitis that dictated a more thorough investigation of the lower abdomen that led to the discovery of a second retrocecal inflamed appendix. Formal appendectomy was then performed for both processes. The patient had an uneventful recovery and was discharged on the fourth postoperative day. DISCUSSION: Double appendix represents a challenging clinical scenario in cases of right lower quadrant pain. CONCLUSION: Life threatening consequences with legal extensions can arise from the incomplete removal of both stumps.

Imbalance of tissue inhibitors of metalloproteinases (TIMP) - 1 and - 4 serum levels, in patients with inflammatory bowel disease.

BACKGROUND: Tissue inhibitors of metalloproteinases (TIMPs) play a key role in tissue degradation and remodeling. Since chronic inflammation is associated with tissue remodeling in inflammatory bowel disease (IBD), we evaluated serum TIMP-1 and TIMP-4 levels in IBD patients, in comparison with healthy controls (HC). METHODS: TIMP-1, TIMP-2 and TIMP-4 serum levels were determined in 53 patients with ulcerative colitis (UC), 52 patients with Crohn's disease (CD) and 50 HC, by means of commercially available enzyme-linked immunosorbent assays. The levels of TIMPs were evaluated with regard to the levels of inflammatory markers, such as C reactive protein (CRP) and serum amyloid A (SAA) and the clinical characteristics of patients, so that potential correlations could be recorded. RESULTS: Mean serum TIMP-1 levels were 414.9 +/- 17.6 ng/mL in UC patients, 446.1 +/- 22.8 ng/mL in CD patients and 296.5 +/- 20.6 ng/mL in HC. UC and CD patients had significantly higher serum TIMP-1 levels when compared to HC, (p < 0.0001 in both groups). Mean serum TIMP-1 levels were significantly higher in patients with active IBD (450.5 ng/mL) in comparison with patients with inactive disease (417.3 ng/mL, p = 0.03). Moreover, males showed significantly higher mean serum TIMP-1 levels (399.8 ng/mL), compared to females (368.5 ng/mL, p = 0.04). Mean serum TIMP-2 levels did not differ between UC and CD patients or HC (p > 0.05 in all cases). Mean serum TIMP-4 levels were 1761.2 +/- 67.7 pg/mL in UC patients, 1708.1 +/- 73.4 pg/mL in CD patients and 5573.4 +/- 1246.3 pg/mL in HC. UC and CD patients had significantly lower serum TIMP-4 levels when compared to HC (p = 0.008 and p = 0.02 respectively). Mean serum TIMP-4 levels were significantly lower in males (2772.9 pg/mL), compared to females (3299.0 pg/mL, p = 0.01). In addition, CRP levels showed a statistically significant correlation with TIMP-1 (r = 0.247, p = 0.01), and TIMP-4 levels (r = 0.217, p = 0.03). Similarly, there was a statistically significant correlation between SAA levels and both TIMP-1 (r = 0.264, p = 0.008) and TIMP-4 serum levels (r = 0.212, p = 0.03). CONCLUSION: An imbalance between TIMP-1 and TIMP-4 serum levels is present in IBD patients. TIMP-1 levels could be used not only for diagnostic purposes but also for the assessment of activity in IBD. Gender tends to influence TIMP-1 and TIMP-4 serum levels. These new findings bring into question the potential role of TIMPs in IBD, thus underlining the need for future studies which could offer new insight into this matter.