Accuracy of visual on-site evaluation (Vose) In predicting the adequacy of Eus-guided fine needle biopsy: A single center prospective study.

OBJECTIVE: Endoscopic ultrasound is the standard procedure for the diagnosis of pancreatic lesions and new needles have been developed to improve tissue acquisition (FNB). Rapid onset evaluation (ROSE) decreases the number of needle passes but is not always available. We introduced an easy and rapid method of direct classification of EUS-FNB sample namely Visual on-site evaluation (VOSE). AIMS: To assess the accuracy of VOSE in predicting the histological adequacy of specimens. To evaluate the diagnostic power of FNB and the rate of core tissue obtained. METHODS: Prospective single center study on patients with pancreatic lesions that underwent EUS-FNB. VOSE parameters were presence of blood, macroscopic visible core (MVC), number, color and length of specimen. The association between VOSE tool and histological adequacy was assessed. Fisher's exact test and Student's t-test used to compare categorical and continuous variables. Logistic regression analysis was used to assess association between variables. RESULTS: 99 patients (58.6% male; mean age 68.4 ± 10) enrolled, including 102 lesions. Total number of passes was 358 with median number of 4 (range, 2-4). The 92.7% of samples were adequate and it was higher with the 22-G needle than with 25G (96.5% vs 89.2% p 0.01). VOSE "red-mixed specimen" was associated with a higher probability of histological adequacy (OR 2.39 95% CI 1.03-5.42 p = 0.04). CONCLUSIONS: The VOSE tool "red-mixed specimen" can be used to predict the histological adequacy and guide the number of needle passes. Overall, FNB provides a high rate of adequate and diagnostic specimen and high rate of core tissue especially with the 22G needle.

Role of fluorescence confocal microscopy for rapid evaluation of EUS fine-needle biopsy sampling in pancreatic solid lesions.

BACKGROUND AND AIMS: EUS fine-needle biopsy (EUS-FNB) sampling is the standard procedure for diagnosis of pancreatic lesions. Fluorescence confocal microscopy (FCM) allows imaging of tissues in the fresh state, requiring minimal preparation without damage or loss of tissue. Until now, no data exist on FCM in the field of microhistologic specimens. We aimed to assess the diagnostic performance of FCM in predicting histologic adequacy of EUS-FNB samples in pancreatic solid lesions and to assess the agreement between FCM evaluation and final histology. METHODS: In this single-center prospective study on consecutive patients with pancreatic lesions receiving EUS-FNB, the obtained samples have been evaluated at FCM and classified as "inadequate" or "adequate" (benign, suspicious, or malignant). The kappa test was used to quantify agreement. The diagnostic accuracy of FCM was assessed. A P < .05 was considered to be statistically significant. RESULTS: From April 2020 to September 2020, 81 patients were enrolled. In all cases FCM showed the macro image of the sample and created a digital image. Of the samples, 92.6% was defined as adequate at the FCM evaluation and confirmed at histopathology. Histologic diagnoses were 8% benign, 17.3% atypical/suspicious, and 74.7% malignant with satisfactory agreement with the FCM evaluation (Cohen's κ coefficient, .95; 95% confidence interval [CI], .89-1.01; P = .001). The sensitivity of the FCM evaluation was 100% (95% CI, 95%-100%), specificity 66.7% (95% CI, 22.3%-95.7%), accuracy 97% (95% CI, 90.7%-99.7%), positive predictive value 97% (95% CI, 91.8%-99%), and negative predictive value 100%. CONCLUSIONS: FCM represents a new technique successfully applicable to microhistologic specimens. It provides fast information about sample adequacy in small specimens with good agreement in the final histology.

Intrahepatic cholangiocarcinoma: Evolving strategies in management and treatment.

Intrahepatic cholangiocarcinoma is the second most frequent primary liver cancer after hepatocellular carcinoma. According to International Classification of Diseases-11 (ICD-11), intrahepatic cholangiocarcinoma is identified by a specific diagnostic code, different with respect to perihilar-CCA or distal-CCA. Intrahepatic cholangiocarcinoma originates from intrahepatic small or large bile ducts including the second-order bile ducts and has a silent presentation that combined with the highly aggressive nature and refractoriness to chemotherapy contributes to the alarming increasing incidence and mortality. Indeed, at the moment of the diagnosis, less than 40% of intrahepatic cholangiocarcinoma are suitable of curative surgical therapy, that is so far the only effective treatment. The main goals of clinicians and researchers are to make an early diagnosis, and to carry out molecular characterization to provide the patient with personalized treatment. Unfortunately, these goals are not easily achievable because of the heterogeneity of this tumor from anatomical, molecular, biological, and clinical perspectives. However, recent progress has been made in molecular characterization, surgical treatment, and management of intrahepatic cholangiocarcinoma and, this article deals with these advances.

Surgical treatment of isolated lung and adrenal metastasis from colorectal cancer. Case report.

INTRODUCTION: Up to 30% of stage I and II colorectal cancers (CRCs) treated with surgical resection alone show disease recurrence, indicating that lymph node (LN) involvement was probably underestimated. Lung is a common site of CRC metastasis, whereas adrenal glands are rarely involved. CASE REPORT: On July 2004 a 56-year old woman underwent left hemicolectomy for a stage I sigmoid cancer. Four years later a lobectomy was performed for an isolated lung metastasis; thirteen months thereafter she underwent left adrenalectomy for adrenal metastasis. No lymph node involvement has ever been demonstrated either histopathologically or radiologically. At present, the patient is alive and apparently disease-free. DISCUSSION: The presence of LN occult metastasis, that might explain recurrence in stage I and II CRCs, has recently been investigated by means of immunohistochemistry and polymerase chain reaction; evidence of LN metastasis obtained with the latter technique is associated to a worse outcome. There have been very few cases that resemble our patient's neoplastic progression and they were either stage III neoplasms or rectal cancers. Our patient's primitive localization in the sigmoid colon makes it difficult to imagine why the liver has not been a site of metastasis. Finally, surgery has an important role in treating isolated metastasis in both lungs and adrenal glands. KEYWORDS: Colorectal cancer, Lung metastasis, Solitary adrenal metastasis.

Eosinophilic Esophagitis: Cytokines Expression and Fibrotic Markers in Comparison to Celiac Disease.

INTRODUCTION: Eosinophilic esophagitis (EoE) is now recognized as the main inflammatory condition that leads to fibrosis, unlike other chronic inflammatory gastrointestinal diseases, such as celiac disease. The aim of our study is to characterize the collagen deposition and cytokine expression involved in the fibrogenic response in patients affected by EoE in comparison to celiac disease. MATERIALS AND METHODS: Consecutive patients with a clinical suspicion of untreated EoE or active celiac disease were enrolled. In the control group, patients with negative upper endoscopy were included. Total RNA was isolated from biopsy specimens using a commercial kit (SV Total RNA Isolation System, Promega Italia Srl). Quantitative real-time PCR (qRT-PCR) was performed in triplicate using a StepOne™ Real-Time PCR instrument (Thermo Fisher Scientific, Monza, Italy). mRNA encoding for inflammatory molecules: interleukin 4 (IL-4), interleukin 5 (IL-5), interleukin 13 (IL-13), and fibrotic markers: transforming growth factor beta 1 (TGF-ß), mitogen-activated protein kinase kinase kinase 7 (MAP3K7), serpin family E member 1 (SERPINE1), were quantified using TaqMan Gene Expression Assays (Applied Biosystems). RESULTS: In EoE, the qPCR analysis showed an increase in all the inflammatory cytokines. Both IL-5 and Il-3 mRNA expression resulted in a statistically significant increase in oesophageal mucosa with respect to the celiac duodenum, while no differences were present in IL-4 expression. TGF-ß expression was similar to the controls in the mid esophagus but reduced in the distal EoE esophagus (RQ: 0.46 ± 0.1). MAP3K7 expression was reduced in the mid esophagus (RQ: 0.59 ± 0.3) and increased in the distal esophagus (RQ: 1.75 ± 0.6). In turn, the expression of SERPINE1 was increased in both segments and was higher in the mid than in the distal esophagus (RQ: 5.25 ± 3.9, 1.92 ± 0.9, respectively). Collagen deposition was greater in the distal esophagus compared to the mid esophagus [18.1% ± 8 vs. 1.3% ± 1; p = 0.008]. CONCLUSIONS: The present study confirms the esophageal fibrotic involution involving the distal esophagus and shows that the inflammatory pathway in EoE is peculiar to this disease and different from other chronic inflammatory gastrointestinal disorders such as celiac disease.

The relationship between alexithymia and circulating cytokine levels in subjects undergoing upper endoscopy.

OBJECTIVE: Despite emerging evidence suggesting a link between alexithymia and immune function, previous studies yielded contrasting results. The proposed link between alexithymia and immune function remains controversial as does the role, in this relationship, of anxiety, depression and subjective stress. The aim of the study is to investigate the possible association between alexithymia and circulating levels of cytokines in subjects awaiting an upper endoscopy, a stressful procedure, controlling for anxiety levels, depression and subjective stress. METHODS: Participants were recruited from among consecutive patients referred for routine diagnostic upper endoscopy. All participants completed the Toronto Alexithymia Scale (TAS-20), the Hospital Anxiety and Depression Scale, and the Stress-related Vulnerability Scale. Serum levels of IL-1ß, IL-4, IL-6, IL-10, TNF-α and IFN-γ were measured by ELISA. RESULTS: Of the 90 subjects initially approached, 68 completed the study. The TAS-20 identified 22 alexithymic and 36 non-alexithymic patients. ELISA detected significantly lower IL-4 and IL-6 concentrations in alexithymic than in non-alexithymic patients. According to multiple linear regression analysis, alexithymia predicted low IL-4 and IL-6 levels in the sample overall, independently of stress, anxiety, depression and other possible confounders. No between-group differences were found in serum levels of IFN-γ, IL-1ß, and TNF-α. CONCLUSION: These findings argue against an isolated shift towards pro-inflammatory or anti-inflammatory mediators and suggest that circulating cytokine profiles differ in alexithymic and non-alexithymic subjects.

Rives technique is the gold stardard for incisional hernioplasty. An institutional experience.

AIM: We report our clinical experience with incisional hernia surgery and we retrospectively analyze the outcomes obtained with the different techniques of repair used, confirming that Rives-Stoppa procedures actually represent the gold standard for incisional hernia. MATERIAL OF STUDY: 334 patients were observed for incisional hernioplasty at our Department of Surgery from 1996 to 2007. They were treated according to the following surgical procedures: 44 primary direct closures; 246 Rives-Stoppa procedures; 9 Chevrel procedures; 35 intraperitoneal repairs. The outcomes were considered in terms of postoperative surgical complications. RESULTS: In total, we had 13 cases of hernia recurrence (3.9%), 14 cases of infections (4.2%), 7 cases ofseroma/hematoma (2.9%) and one case of acute respiratory insufficiency. DISCUSSION: The choice of the surgical technique depends on several factors, such as the size of the hernia defect and the representation of the anatomical structures, essential for the reconstruction of the abdominal wall. We abandoned Chevrel technique due to high rate of recurrence and infective complications and reserved the intra-peritoneal repair only for cases where a fascial layer could not be reconstructed. Instead, the primary direct closure should be considered for high risk patients because of its low surgical impact, although it is characterized by higher incidence of recurrence. Combining the Rives-Stoppa technique with some personal technical modifications, we obtained acceptable results in terms of recurrence rate and morbidity. CONCLUSIONS: Rives-Stoppa procedures are the current standard of care for the surgical repair of incisional hernia and our treatment of choice.

A new micro-forceps for endoscopic ultrasound-guided through-the-needle biopsy in the diagnosis of pancreatic cystic lesions: Single center experience.

BACKGROUND AND AIM: Endoscopic ultrasound (EUS)-guided through-the-needle biopsy (TTNB) has improved the diagnostic algorithm of pancreatic cystic neoplasms (PCNs). Recently, a new through-the-needle micro-forceps device (Micro Bite, MTW Endoskopie Manufakture) has been introduced. The primary aim was to assess the safety and technical success of this new type of micro-forceps. The secondary aim was to evaluate the diagnostic role of EUS-TTNB. METHODS: Retrospective study of consecutive patients receiving EUS-TTNB for the diagnosis of PCNs. Two micro-forceps were used: Moray Micro-forceps and Micro-Bite. Cystic fluid was collected for cytological analysis. Categorical variables were analyzed by Fisher's exact test, and continuous variables were analyzed by Student's t-test. P < 0.05 was considered significant. RESULTS: Forty-nine patients enrolled in the study (24% male; mean age 63 ± 14 years). TTNB was successfully performed in all patients. A diagnostic sample was obtained in 67.3% PCNs with TTNB compared with 36.7% with cyst fluid cytology (P 0.01). Adverse events rate was 10.2% and occurred in older patients (76.6 ± 5.4 vs 61.3 ± 13.7 P = 0.02). The 51% underwent EUS-TTNB with Micro Bite. A diagnostic sample was obtained in 52% PCNs with Micro Bite compared with 24% obtained with cyst fluid cytology (P = 0.07). Comparing the two devices, the rate of diagnostic sample obtained with the micro-forceps Moray was higher than that obtained with the Micro Bite (20/24 [83.3%] vs 13/25 [52%] P 0.03). CONCLUSIONS: EUS-TTNB increases the diagnostic yield of PCNs. The new Micro-Bite could represent a valid alternative to the currently used Moray Micro-forceps, but its diagnostic rate is still suboptimal and further studies are needed.

IL-13 mRNA Tissue Content Identifies Two Subsets of Adult Ulcerative Colitis Patients With Different Clinical and Mucosa-Associated Microbiota Profiles.

BACKGROUND AND AIMS: A personalized approach to therapy hold great promise to improve disease outcomes. To this end, the identification of different subsets of patients according to the prevalent pathogenic process might guide the choice of therapeutic strategy. We hypothesize that ulcerative colitis [UC] patients might be stratified according to distinctive cytokine profiles and/or to a specific mucosa-associated microbiota. METHODS: In a cohort of clinically and endoscopic active UC patients and controls, we used quantitative PCR to analyse the mucosal cytokine mRNA content and 16S rRNA gene sequencing to assess the mucosa-associated microbiota composition. RESULTS: We demonstrate, by means of data-driven approach, the existence of a specific UC patient subgroup characterized by elevated IL-13 mRNA tissue content separate from patients with low IL-13 mRNA tissue content. The two subsets differ in clinical-pathological characteristics. High IL-13 mRNA patients are younger at diagnosis and have a higher prevalence of extensive colitis than low IL-13 mRNA patients. They also show more frequent use of steroid/immunosuppressant/anti-tumour necrosis factor α therapy during 1 year of follow-up. The two subgroups show differential enrichment of mucosa-associated microbiota genera with a prevalence of Prevotella in patients with high IL-13 mRNA tissue content and Sutterella and Acidaminococcus in patients with low IL-13 mRNA tissue content. CONCLUSION: Assessment of mucosal IL-13 mRNA might help in the identification of a patient subgroup that might benefit from a therapeutic approach modulating IL-13. PODCAST: This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.

Functional magnetic resonance in the evaluation of oesophageal motility disorders.

Functional magnetic resonance imaging (fMRI) has been recently proposed for the evaluation of the esophagus. Our aim is to assess the role of fMRI as a technique to assess morphological and functional parameters of the esophagus in patients with esophageal motor disorders and in healthy controls. Subsequently, we assessed the diagnostic efficiency of fMRI in comparison to videofluoroscopic and manometric findings in the investigation of patients with esophageal motor disorders. Considering that fMRI was shown to offer valuable information on bolus transit and on the caliber of the esophagus, variations of these two parameters in the different types of esophageal motor alterations have been assessed. fMRI, compared to manometry and videofluoroscopy, showed that a deranged or absent peristalsis is significantly associated with slower transit time and with increased esophageal diameter. Although further studies are needed, fMRI represents a promising noninvasive technique for the integrated functional and morphological evaluation of esophageal motility disorders.