V-056 LAPAROSCOPIC VENTRAL HERNIA REPAIR WITH GORE SINECOR INTRAPERITONEAL BIOMATERIAL: OUR CENTER EXPERIENCE

Aim

Ventral hernias including incisional ones are very common in our population. Mesh reinforcement options for ventral/incisional hernia repair continue to evolve with advances in polymer science and better understanding of the extracellular matrix. Consensus on the safety and efficacy of these various types of synthetic and biologic mesh has yet to be reached.

Intraperitoneal onlay mesh (IPOM) is the laparoscopic technique most frequently used in our center to treat umbilical and abdominal ventral defects sized 3 cm to 8 cm. Our equipe built an expertise with Gore DualMesh prosthesis (2% recurrence ratio in our center); we used the Gore Sinecor Intraperitoneal Biomaterial for the first time here.

Methods

Symptomatic supraumbilical incisional hernia in a 74 years old man; parietal defect sized 7×8 cm. We performed an Ipom repair procedure using a 20×25 cm Gore Sinecor Intraperitoneal Biomaterial, trimmed to 18×20 cm. Follow-up at one and six months from surgery.

Results

The patient was discharged the day after surgery. He did not complain severe pain in the first week after surgery and he only use Paracetamolo 1g die as antalgic therapy. After seven days he resumed his daily activities.

He did not experience any short-term sieroma nor long-term complication at follow up.

Conclusions

The Gore Sinecor Intraperitoneal Biomaterial, while maintaining a firm peritoneal adhesivity, has a better handling and feels lighter than the Gore DualMesh we routinely use. The transparency makes it possible to visualize the overlying abdominal wall, allowing a safer tacs positioning.

P-090 EMERGENCY INTRAPERITONEAL ONLAY MESH REPAIR OF INCARCERATED VENTRAL E INCISIONAL HERNIA

Aim

Abdominal wall hernia surgery is the frequent surgical operation. Incarceration and strangulation are the complications for patients going to emergency surgery clinics.Laparoscopic approach in emergency is controversial. IPOM treatment permits safe hernia reduction, accurate abdominal exploration,diagnosis and treatment of unknown hernia.

Material and Methods

in one year,we operated 12 urgent ventral hernia patients with IPOM technique. All patientsshowed hemodynamic stability. We evaluated safety of hernia reduction, conversion rate,operative time,hospital stay, and prosthesis infection.

Results

Nine patients underwent surgery for incarcerated incisional hernia, 3 patients for primary incarcerated ventral hernia. We used a laparoscopic approach. In 10 cases,we placed an intraperitoneal mesh. In two cases, we converted to open surgery, because of small bowel injury. It was never necessary to perform Intestinal resection for strangulated hernia.Contents of hernia sacs were omentum (7 patients), large bowel (1 patients), 4 omentum and small bowel (4 patients). Patients presented signs of small bowel obstruction. Average size of the defect was 6cm.Average operative time was 91 min, the mean post-operative hospital stay was 3.5 days. Post-operative complications weren't recorded. There wasn't mortality. During the follow-up none patients had mesh infection or hernia recurrence.

Conclusion

In emergency the Intraperitoneal Onlay Mesh Repair of Incarcerated Ventral and Incisional Hernia allowed safe adesiolysis, bowel reduction. Laparoscopic approach was associated to low post-operative complications even in emergency setting.

Diagnostic Accuracy of EndoFaster® and Narrow-Band Imaging Endoscopy in Patients with Impaired Gastric Acid Secretion: A Real-Time Prospective Study

BACKGROUND

EndoFaster® analyzes gastric juice in real time during gastroscopy allowing the detection of hypo-achlorhydric conditions, like corpus atrophic gastritis. Narrow-band imaging (NBI) endoscopy allows to accurately detect and perform target biopsies in areas of intestinal metaplasia, a histological change often associated to corpus atrophic gastritis.

AIMS

To compare the diagnostic accuracy of EndoFaster® with histological evaluation for corpus atrophic gastritis through high-resolution (HR) NBI targeted biopsies.

METHODS

Prospective study on consecutive adult patients undergoing gastroscopy between April and November 2018. Patients in therapy with proton pump inhibitors, previous gastric surgery, and/or known gastric neoplasia were excluded. At the beginning of gastroscopy, gastric juice was aspirated and analyzed by EndoFaster® in 15 seconds. Endoscopists were blinded to the report of EndoFaster®. Evaluation of gastric mucosa in HR-white light was firstly performed, then with HR-NBI allowing to perform targeted biopsies on areas suspected for intestinal metaplasia; otherwise, biopsies were performed according to the updated Sydney System protocol and sent for histopathological evaluation.

RESULTS

Overall, 124 patients were included [64% F; 56 (18-85) years]. Corpus atrophic gastritis was present in 41.9% of patients. EndoFaster® showed an accuracy for corpus atrophic gastritis diagnosis, compared to histopathological evaluation as gold standard, of 87.1% and a sensitivity, specificity, PPV, and NPV of 78.8%, 93.1%, 89.1%, and 85.9%, respectively. pH showed a positive correlation with the severity score of atrophy (r = 0.67, 95% CI: 0.73-0.81, and p < 0.0001). EndoFaster® allowed to diagnose corpus atrophic gastritis in 3.7% of patients negative to NBI (corpus atrophic gastritis without intestinal metaplasia).

CONCLUSION

EndoFaster® seems a promising tool to diagnose corpus atrophic gastritis. The evaluation of hypo-achlorhydria during gastroscopy can address bioptic sampling in corpus atrophic gastritis patients without intestinal metaplasia.

Cameron lesions: A still overlooked diagnosis. Case report and systematic review of literature

Cameron lesions are erosive-ulcerative alterations of gastric mucosa occurring in patients with large hiatal hernia, potentially causing gastrointestinal bleeding and iron deficiency anaemia. Diagnosis may be challenging, and not infrequently erosions are overlooked at endoscopy, so that repeated and unnecessary diagnostic procedures are performed, particularly in those patients with chronic anaemia. We described two peculiar cases of patients with iron deficiency anaemia in whom Cameron lesions were either overlooked or misinterpreted. By reviewing data of 22publications reporting endoscopic and clinical data of 140patients, we noted a large prevalence of females (75%). The most frequent presenting symptoms were anaemia (62%) and overt gastrointestinal bleeding (36%). Noteworthy, as many as 69% of patients underwent one or more previous upper endoscopy before diagnosis of Cameron lesion was achieved. Patients were mainly treated with proton pump inhibitor (PPI) therapy and iron supplementation. Moreover, endoscopic haemostasis was performed in 10% of case, blood transfusion was required in one third of cases, and a similar quote of patients underwent a surgical approach for hiatal hernia repair. The observation that as many as 60% patients were already receiving standard PPI therapy when diagnosis was performed would suggest that either long-term treatment with adequate dose PPI or surgical approach for hiatal hernia repair is required. In conclusion, Cameron lesion is still an overlooked diagnosis in patients with iron deficiency anaemia in whom a 5-9.2% prevalence has been reported.

Effect of nutrient deprivation on the expression and the epigenetic signature of sirtuin genes

BACKGROUND AND AIM

Over the last decades advances in understanding the molecular bases of the close relationship between nutrition, metabolism, and diseases have been impressive. However, there are always novel frontiers coming up and epigenetics is one of these. Sirtuins, are pivotal factors in the control of metabolic pathways according to nutrient availability. In the present study we evaluated the effect of nutrient deprivation on expression, DNA methylation and chromatin status of the sirtuin genes.

METHODS AND RESULTS

We performed these studies in mouse hepatoma cells, that were grown in standard medium, or in media containing low glucose concentration, or no glucose, or no amino acids. We applied quantitative real-time PCR to cDNA, methylation-enriched DNA and nuclease-treated DNA in order to evaluate gene expression, DNA methylation, and chromatin condensation, respectively. This study shows that the expression of sirtuin genes varies following nutrient deprivation. Moreover, we observed that changes of DNA methylation and chromatin condensation occur at the transcription start site of sirtuin genes following nutrient deprivation.

CONCLUSIONS

Epigenetic mechanisms may have a role in the sirtuin response to nutrient deprivations in cultured hepatoma cells. Replicating these results in vivo to achieve a comprehensive understanding of the epigenetic control of sirtuin expression following nutrient deprivations might open up novel therapeutic possibilities to cure metabolic diseases and promote human health.

Characterization of circadian COPD symptoms by phenotype: Methodology of the STORICO observational study

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide. The symptoms of COPD are troublesome, variable, can occur during all parts of the 24-h day and have a substantial impact on patients' health status, quality of life and healthcare resource utilization. Reducing symptoms, improving health status and increasing physical activity are major goals in the management of stable COPD. In order to provide effective, patient-oriented care, patients should be evaluated on the basis of lung function, frequency of symptoms and patient-perceived impact of symptoms on their lives and treatment decisions made on a case-by-case basis. The identification of COPD phenotypes is an evolving debate and literature data about the circadian variation of COPD symptoms according to phenotypes are nowadays lacking. The ongoing STORICO (STudio Osservazionale sulla caratteRizzazione dei sIntomi delle 24 ore nei pazienti con BPCO) study (NCT03105999) is aimed to describe by clinically defined phenotypes the frequency and 12-month evolution of early-morning, day- and night-time COPD symptoms in a cohort of 600 Italian patients with stable COPD. Secondary objectives include the description of the 12-month variation of outcomes of interest according to phenotypes and of the healthcare resources utilization (overall and by phenotype) during 12-month observation. An exploratory analysis will be conducted aimed to phenotype COPD patients in an alternative researcher-independent way based on circadian pattern of symptoms combined with measures of respiratory function, health-related quality of life and comorbidity. The present paper describes the methodology of the STORICO study.

Liver Regeneration Induced By Extracorporeal Portal Vein Arterialization in a Swine Model of Carbon Tetrachloride Intoxication

INTRODUCTION

This study aimed to determine whether a controlled portal blood arterialization by a liver extracorporeal device (L.E.O2 NARDO) is effective in treating acute hepatic failure (AHF) induced in swine by carbon tetrachloride (CCl4) administration.

MATERIALS AND METHODS

Sixteen swine with AHF induced by intraperitoneal injection of CCl4 in oil solution were randomly divided into 2 groups: animals that received L.E.O2 NARDO treatment 48 hours after the intoxication (study group; n = 8); and animals that were sham operated 48 hours after the intoxication (control group; n = 8). Blood was withdrawn from the iliac artery and reversed in the portal venous system by an interposed extracorporeal device. Each treatment lasted 6 hours. The survival was assessed at 5 days after L.E.O2 NARDO treatment or sham operation. In both groups blood samples were collected for biochemical analysis at different study time and liver biopsies were performed 48 hours after intoxication and at humane killing.

RESULTS

In the study group decreased transaminases levels and a more rapid international normalized ratio (INR) recover were detected as compared with the control group. Six animals of the study group (75%) versus 1 animal (12.5%) of the control group survived at 5 days after surgery with a statistically significant difference (P < .05). Liver biopsies performed at humane killing showed damaged areas of the livers reduced in the study group compared with biopsies of the control group.

CONCLUSIONS

Arterial blood supply in the portal system through the L.E.O2 NARDO device is easily applicable, efficacious, and safe in a swine model of AHF induced by CCl4 intoxication.

Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and safety of endoscopic resection of large colorectal polyps.

DESIGN

Relevant publications were identified in MEDLINE/EMBASE/Cochrane Central Register for the period 1966-2014. Studies in which ≥20 mm colorectal neoplastic lesions were treated with endoscopic resection were included. Rates of postendoscopic resection surgery due to non-curative resection or adverse events, as well as the rates of complete endoscopic removal, invasive cancer, adverse events, recurrence and mortality, were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random effect models. I2 statistic was used to describe the variation across studies due to heterogeneity. Meta-regression analysis was also performed.

RESULTS

50 studies including 6442 patients and 6779 large polyps were included in the analyses. Overall, 503 out of 6442 patients (pooled rate: 8%, 95% CI 7% to 10%, I2=78.6%) underwent surgery due to non-curative endoscopic resection, and 31/6442 (pooled rate: 1%, 95% CI 0.7% to 1.4%, I2=0%) to adverse events. Invasive cancer at histology, non-curative endoscopic resection, synchronous lesions and recurrence accounted for 58%, 28%, 2.2% and 5.9% of all the surgeries, respectively. Endoscopic perforation occurred in 96/6595 (1.5%, 95% CI 1.2% to 1.7%) polyps, while bleeding in 423/6474 (6.5%, 95% CI 5.9% to 7.1%). Overall, 5334 patients entered in surveillance, 502/5836 (8.6%, 95% CI 7.9% to 9.3%) being lost at follow-up. Endoscopic recurrence was detected in 735/5334 patients (13.8%, 95% CI 12.9% to 14.7%), being an invasive cancer in 14/5334 (0.3%, 95% CI 0.1% to 0.4%). Endoscopic treatment was successful in 664/735 cases (90.3%, 95% CI 88.2% to 92.5%). Mortality related with management of large polyps was reported in 5/6278 cases (0.08%, 95% CI 0.01% to 0.15%).

CONCLUSIONS

Endoscopic resection of large polyps appeared to be an extremely effective and safe intervention. However, an adequate endoscopic surveillance is necessary for its long-term efficacy.

Spondylodiscitis (Andersson lesion) in psoriatic spondyloarthritis: a rare event successfully treated with an anti-TNF therapy

Spondylodiscitis (Andersson lesion) is an infrequent and late complication of advanced ankilosing arthritis. Scanty data on the efficacy of anti-TNF therapy for these lesions are available. To our knowledge, only few cases of spondylodiscitis occurring in patients with psoriatic arthritis were reported in literature. We describe the case of a patient with psoriatic arthritis who early developed Andersson lesions successfully treated with infliximab plus methotrexate therapy.

Systematic review with meta-analysis: the incidence of advanced neoplasia after polypectomy in patients with and without low-risk adenomas

BACKGROUND

Patients with one to two tubular adenomas <1 cm in size without high-grade dysplasia (low-risk group) are considered at low risk for colorectal cancer. However, it is uncertain whether they have the same risk of subsequent advanced neoplasia as those with no neoplasia at baseline colonoscopy.

AIM

To compare incidence of metachronous advanced neoplasia between patients in the low-risk adenoma group and those without neoplasia at index colonoscopy.

METHODS

Relevant publications were identified by MEDLINE/EMBASE and other databases for the period 1992-2013. Studies comparing the incidence of post-polypectomy advanced neoplasia (adenomas ≥10 mm/high-grade dysplasia/villous or cancer) between the low-risk group and patients without colorectal neoplasia at the first colonoscopy were included. Detection rates for advanced neoplasia at endoscopic surveillance were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random-effect models. Inter-study heterogeneity was assessed using the I(2) statistic.

RESULTS

Seven studies provided data on 11 387 patients. Mean surveillance periods ranged between 2 and 5 years. Altogether, 267 patients with post-polypectomy advanced neoplasia were detected in the two groups. The incidence of advanced neoplasia was 1.6% (119/7308) in those without neoplasia and 3.6% (148/4079) in those with low-risk adenoma, respectively, corresponding to a relative risk of 1.8 (95% CI: 1.3-2.6). Inter-study heterogeneity was only moderate (I(2) : 37%). No publication bias was present.

CONCLUSIONS

Patients with low-risk adenomas at baseline had a higher risk of metachronous advanced neoplasia than the group with no adenomas at baseline, though the absolute risk was low in both groups.

Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline

BACKGROUND AND AIM

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the choice amongst regimens available for cleansing the colon in preparation for colonoscopy.

METHODS

This Guideline is based on a targeted literature search to evaluate the evidence supporting the use of bowel preparation for colonoscopy. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence.

RESULTS

The main recommendations are as follows. (1) The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). (2) The ESGE recommends a split regimen of 4 L of polyethylene glycol (PEG) solution (or a same-day regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation, high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence). (3) The ESGE advises against the routine use of sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence).

A retrospective analysis of early and late outcome of biodegradable stent placement in the management of refractory anastomotic colorectal strictures

BACKGROUND

Benign colorectal strictures are treated conventionally by endoscopic dilation. Experience using SEMS for benign colonic strictures is limited, and outcomes to date have been disappointing. Refractory colorectal strictures remain challenging to be treated with surgery. Polydioxanone-based stent are biodegradable (BD) stent CE approved for esophageal strictures. This study was designed to investigate retrospectively the safety and the efficacy of these stents for the management of strictures refractory to multiple sessions of dilation.

METHODS

Patients with postsurgical benign strictures located within 20 cm from anal verge, refractory to mechanical or pneumatic dilation (at least 3 sessions) were included in this analysis. Clinical success was defined as the absence of occlusive symptoms and the ability to pass through the stricture with a regular size colonoscope. All patients were predilated before stent placement. Stents were released under fluoroscopic control. All patients were under stool softeners for 3 months. Follow-up was scheduled with endoscopic and fluoroscopic controls within 90 days from stent deployment and afterwards by telephone interview and/or ambulatory consultation.

RESULTS

Eleven patients (7 males, mean age 62.3 ± 8.5 years) were included. Technical success was achieved in all the patients. Stent migration was observed in four patients within the first 2 weeks after stent placement. Stent migration was followed by recurrence of stricture and obstructive symptoms in all the cases. Among the seven patients who completed the process of stent biodegradation, five of them had complete resolution of the stricture and relief of symptoms. Two of 11 patients required surgical treatment during the follow-up period (mean 19.8 (range 42-15) months). The overall success rate of the BD stent was 45 %.

CONCLUSIONS

This retrospective analysis of a limited number of patients demonstrated that nondedicated esophageal BD stents are associated with high risk of migration and clinical success in less than 50 % of patients. Dedicated stents with large diameter and antimigration findings could potentially improve the outcome of patients with refractory benign colorectal strictures.

Meta-analysis: adherence to colorectal cancer screening and the detection rate for advanced neoplasia, according to the type of screening test

BACKGROUND

A variety of tests have been proposed for colorectal cancer (CRC), giving rise to uncertainty regarding the optimal approach. The efficacy and effectiveness of different tests are related to both screened participation and the detection rate.

AIM

To perform a meta-analysis on adherence and detection rates of CRC screening tests.

METHODS

Relevant publications were identified by MEDLINE/EMBASE and other databases for the period 1999-2012. A previous systematic review was used for the period before 1966-1999. RCTs and controlled studies including a direct comparison of the uptake rates among different options for CRC screening were included. Adherence and detection rates for advanced neoplasia and cancer were extracted. Risk for bias was ascertained according to CONSORT guidelines. Forrest plots were produced based on random-effect models.

RESULTS

Fourteen studies provided data on 197 910 subjects. Endoscopic strategies were associated with a lower participation (RR: 0.67, 95% CI: 0.56, 0.80) rate, but a higher detection rate of advanced neoplasia (RR: 3.21, 95% CI: 2.38, 4.32) compared with faecal tests. FIT was superior to g-FOBT with regard to both adherence (RR: 1.16, 95% CI 1.03, 1.30) and detection of advanced neoplasia (RR: 2.28, 95% CI 1.68, 3.10) and cancer (RR: 1.96, 95% CI: 1.2, 3.2).

CONCLUSION

The superior accuracy of endoscopy compared with faecal tests minimised any impact of the participation rate in determining the detection rate of advanced neoplasia in a screening setting.

Evolution of bisphosphonate-related osteonecrosis of the jaw in patients with multiple myeloma and Waldenstrom's macroglobulinemia: a retrospective multicentric study

Bisphosphonates (BPs) are used intravenously to treat cancer-related conditions for the prevention of pathological fractures. Osteonecrosis of the jaw (BRONJ) is a rare complication reported in 4-15% of patients. We studied, retrospectively, 55 patients with multiple myeloma or Waldenstrom's macroglobulinemia followed up from different haematological departments who developed BRONJ. All patients were treated with BPs for bone lesions and/or fractures. The most common trigger for BRONJ was dental alveolar surgery. After a median observation of 26 months, no death caused by BRONJ complication was reported. In all, 51 patients were treated with antibiotic therapy, and in 6 patients, this was performed in association with surgical debridement of necrotic bone, in 16 with hyperbaric O(2) therapy/ozonotherapy and curettage and in 12 with sequestrectomy and O(2)/hyperbaric therapy. Complete response was observed in 20 cases, partial response in 21, unchanged in 9 and worsening in 3. The association of surgical treatment with antibiotic therapy seems to be more effective in eradicating the necrotic bone than antibiotic treatment alone. O(2) hyperbaric/ozonotherapy is a very effective treatment. The cumulative dosage of BPs is important for the evolution of BRONJ. Because the most common trigger for BRONJ was dental extractions, all patients, before BP treatment, must achieve an optimal periodontal health.

Rheumatoid arthritis: a complication of aromatase inhibitor therapy?

We report the case of a 56-year-old woman treated with aromatase inhibitors for a breast cancer. Following one year of such therapy, the patient presented with widespread osteoarthrealgia. The clinical picture worsened 3 years later when the pain became more severe with swelling and stiffness involving several joints in a symmetric fashion. Biochemical analysis showed an increase of ESR, CRP and rheumatoid factor, as well as of anti-CCP antibodies. The x-ray was compatible with a diagnosis of rheumatoid arthritis (RA). Therapy with methotrexate, prednisol one, bisphosphonates and vitamin D was started, achieving a quick clinical remission. Aromatase inhibitors have been shown to alter the distribution of Th1/Th2 lymphocytes and increase the level of RANKL. A possible role of aromatase inhibitors in RA development has been further addressed.

Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) has been proposed for large colorectal lesions, due to the high risk of recurrence following endoscopic mucosal resection. However, data on the efficacy and safety of colorectal ESD are still controversial. The aim of the current systematic review was to assess the efficacy and safety of colorectal ESD.

METHODS

A detailed Medline search of papers published during the period 1999-2010 was performed, using the search terms "Endoscopic submucosal dissection," "Colorectal neoplasia," "Colon," or "Rectum." Published studies that evaluated ESD for colorectal lesions were assessed using well-defined inclusion/exclusion criteria, including histological confirmation and surgery for complications. The process was independently performed by two authors. Forest plots on primary (i.e. histologically verified R0 resection and surgery for ESD complications) and secondary end-points were produced based on random-effect models. Heterogeneity was assessed using the I2 statistic. Risk for within-study bias was also ascertained.

RESULTS

A total of 22 studies (20 Asian, two European) provided data on 2841 ESD-treated lesions. The per-lesion summary estimate of R0 resection rate was 88% (95%CI 82%-92%; I2=91%). At meta-regression, carcinoid vs. non-carcinoid series (R0 93% vs. 87%; P=0.04) and Asian vs. European series (R0 88% vs. 65%; P=0.03) appeared to explain the detected heterogeneity. The per-lesion summary estimate of surgery for ESD complications was 1% (95%CI 0%-1%) with a moderate degree of heterogeneity (I2=49%). However, subgrouping of these results according to histological tumor types was not available in the reviewed studies.

CONCLUSIONS

ESD appeared to be an extremely effective technique to achieve R0 resection of large colorectal lesions. The very low rate of surgery for complications also shows the potential safety of this approach.

Safety of cold polypectomy for <10mm polyps at colonoscopy: a prospective multicenter study

BACKGROUND

Cold polypectomy techniques (without electrocautery) by means of biopsy forceps or snare are widely adopted for the removal of subcentimetric polyps. However, few data are available on the safety of this approach. The aim of this study was to assess the safety of cold polypectomy for subcentimetric polyps, as well as the rate of advanced neoplasia in these lesions.

PATIENTS AND METHODS

In a prospective multicenter trial, consecutive patients with at least one < 10-mm polyp at colonoscopy were prospectively included. All of the < 10-mm polyps detected within the study period were removed by cold polypectomy. The rates of immediate or delayed bleeding and other complications were assessed at 7 and 30 days after cold polypectomy by telephone calls. The rate of advanced histology was also assessed. Predictive variables of postpolypectomy bleeding or advanced neoplasia were identified by multivariate analysis.

RESULTS

A total of 1015 < 10-mm polyps in 823 patients (15.5 % on antiplatelet agents) were removed. Of these, 822 (81 %) were ≤ 5 mm and 193 (19 %) were 6 - 9 mm. Immediate postpolypectomy bleeding occurred in 18 patients, corresponding to a per-patient and per-polyp bleeding rate of 2.2 % (95 % confidence interval [CI] 1.2 % - 3.2 %) and 1.8 % (95 %CI 1 % - 2.6 %), respectively. Therapy with antiplatelet agents (odds ratio [OR] 4; 95 %CI 1.5 - 10.6) and larger polyp size (OR 2; 95 %CI 1.1 - 6.9) were independent predictors of bleeding. Bleeding was successfully treated by endoscopic hemostasis in all cases and required no further medical intervention. Advanced neoplasia prevalence in polyps ≤ 5 mm was as high as 8.7 %.

CONCLUSIONS

The results from this study showed the high safety of a cold polypectomy approach for subcentimetric polyps. This was due to the low rate of postpolypectomy bleeding and to the high efficacy of endoscopic hemostasis in its treatment. The high rate of advanced neoplasia in polyps ≤ 5 mm should prompt some caution on the management of these lesions following detection at computed tomography colonography or colon capsule endoscopy.

Cost effectiveness and projected national impact of colorectal cancer screening in France

BACKGROUND

Colorectal cancer (CRC) is a major cause of morbidity and mortality in France. Only scanty data on cost-effectiveness of CRC screening in Europe are available, generating uncertainty over its efficiency. Although immunochemical fecal tests (FIT) and guaiac-based fecal occult blood tests (g-FOBT) have been shown to be cost-effective in France, cost-effectiveness of endoscopic screening has not yet been addressed.

METHODS

Cost-effectiveness of screening strategies using colonoscopy, flexible sigmoidoscopy, second-generation colon capsule endoscopy (CCE), FIT and g-FOBT were compared using a Markov model. A 40 % adherence rate was assumed for all strategies. Colonoscopy costs included anesthesiologist assistance. Incremental cost-effectiveness ratios (ICERs) were calculated. Probabilistic and value-of-information analyses were used to estimate the expected benefit of future research. A third-payer perspective was adopted.

RESULTS

In the reference case analysis, FIT repeated every year was the most cost-effective strategy, with an ICER of €48165 per life-year gained vs. FIT every 2 years, which was the next most cost-effective strategy. Although CCE every 5 years was as effective as FIT 1-year, it was not a cost-effective alternative. Colonoscopy repeated every 10 years was substantially more costly, and slightly less effective than FIT 1-year. When projecting the model outputs onto the French population, the least (g-FOBT 2-years) and most (FIT 1-year) effective strategies reduced the absolute number of annual CRC deaths from 16037 to 12916 and 11217, respectively, resulting in an annual additional cost of €26 million and €347 million, respectively. Probabilistic sensitivity analysis demonstrated that FIT 1-year was the optimal choice in 20% of the simulated scenarios, whereas sigmoidoscopy 5-years, colonoscopy, and FIT 2-years were the optimal choices in 40%, 26%, and 14%, respectively.

CONCLUSIONS

A screening program based on FIT 1-year appeared to be the most cost-effective approach for CRC screening in France. However, a substantial uncertainty over this choice is still present.

Appropriateness of the indication for upper endoscopy: a meta-analysis

BACKGROUND

Application of appropriate indications for upper endoscopy (EGD) should conserve limited endoscopic resources. To perform a systematic review and meta-analysis to assess the efficacy of American Society for Gastrointestinal Endoscopy and European Panel on the Appropriateness of Gastrointestinal Endoscopy guidelines in selecting patients referred for an upper endoscopy relative to the detection of gastro-oesophageal cancer.

METHODS

Studies comparing the appropriateness of EGD indication according to American Society for Gastrointestinal Endoscopy or European Panel on the Appropriateness of Gastrointestinal Endoscopy guidelines and the detection of relevant endoscopic findings and cancer were identified by searching the Medline (1982 to September 2008). Pre-defined outputs of the meta-analysis were sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR-).

RESULTS

We included eight cohort studies comprising 13,856 patients; 10,643 EGD indications were categorized as appropriate, and 3010 (22%) as inappropriate. For relevant findings, the adjusted sensitivity, specificity, LR+, and LR- were 85% (95% CI, 84-86%), 28% (95% CI, 27-29%), 1.18 (95% CI, 1.1-1.3) and 0.6 (95% CI, 0.5-0.7), respectively. For cancer detection, the adjusted sensitivity, specificity, LR+, and LR- were 97% (95% CI, 94-98%), 22% (95% CI, 22-23%), 1.2 (95% CI, 1.1-1.4), and 0.2 (95% CI, 0.05-0.9), respectively.

CONCLUSIONS

For inappropriate EGD, the very low likelihood of cancer argues against endoscopic referral, whereas the low specificity substantially reduces the predictive value of an appropriate indication for both cancer and relevant endoscopic findings.

Systematic review: distribution of advanced neoplasia according to polyp size at screening colonoscopy

BACKGROUND

The impact of not referring sub-centimetre polyps identified at CT colonography upon the efficacy of colorectal cancer screening remains uncertain.

AIM

To determine the distribution of advanced neoplasia according to polyp size in a screening setting.

METHODS

Published studies reporting the distribution of advanced adenomas in asymptomatic screening cohorts according to polyp size were identified by MEDLINE and EMBASE searches. Predefined outputs were the screening rates of advanced adenomas represented by diminutive (< or =5 mm), small (6-9 mm), sub-centimetre (<10 mm) and large (> or =10 mm) polyp sizes.

RESULTS

Data from four studies with 20 562 screening subjects met the primary inclusion criteria. Advanced adenomas were detected in 1155 (5.6%) subjects (95% CI = 5.3-5.9), corresponding to diminutive, small and large polyps in 4.6% (95% CI = 3.4-5.8), 7.9% (95% CI = 6.3-9.4) and 87.5% (95% CI = 86-89.4) of cases respectively. The frequency of advanced lesions among patients whose largest polyp was diminutive, small, sub-centimetre and large in size was 0.9%, 4.9%, 1.7% and 73.5% respectively.

CONCLUSIONS

Based on this systematic review, a 6-mm polyp size threshold for polypectomy referral would identify over 95% of subjects with advanced adenomas, whereas a 10-mm threshold would identify 88% of cases.

Cost-effectiveness of early colonoscopy surveillance after cancer resection

BACKGROUND

Short-interval surveillance colonoscopy at 1 year has been recently recommended following curative-intent surgery for colorectal cancer. However, the efficacy and cost-effectiveness of this endoscopic strategy is largely unknown.

AIM

To assess the clinical and economic impact of early surveillance post-surgical colonoscopy at 1 year in relation to the detection of metachronous colorectal cancer.

METHODS

A decision analysis model was constructed in order to compare a strategy of 1-year endoscopic surveillance versus no early endoscopy following surgical resection for colorectal cancer. A 2-year cancer upstaging was modelled in order to simulate cancer progression in patients with metachronous colorectal cancer who were not referred to early endoscopy. Endoscopic prevalence of metachronous colorectal cancer was estimated from a previous pooled data analysis based on systematic review of the literature. Costs of colonoscopy and cancer care were estimated from Medicare reimbursement data. Outcome measures were the number of early colonoscopies needed to detect one case of cancer or to prevent one cancer-related death and the incremental cost-effectiveness ratio.

RESULTS

The number of early 1-year colonoscopies needed to detect one colorectal cancer and to prevent one colorectal cancer-related death was 143 and 926, respectively. The incremental cost-effectiveness ratio of the early 1-year colonoscopy as compared to a policy of not performing it was $40,313 per life-year gained. The incremental cost-effectiveness ratio of performing early surveillance colonoscopy was sensitive to the changes in cancer prevalence. However, only a reduction from the baseline value of 0.7% to 0.19% was associated with an incremental cost-effectiveness ratio higher than $150,000. Other assumptions about cancer upstaging, initial distribution of cancer, and costs had a lesser influence on incremental cost-effectiveness ratio differences.

CONCLUSIONS

Our study shows that the recently recommended short-interval 1-year surveillance colonoscopy following colorectal cancer resection is a clinically efficient and cost-effective strategy in terms of cancer detection and cancer-specific death prevention.

Systematic review: distribution of advanced neoplasia according to polyp size at screening colonoscopy

BACKGROUND

The impact of not referring sub-centimetre polyps identified at CT colonography upon the efficacy of colorectal cancer screening remains uncertain.

AIM

To determine the distribution of advanced neoplasia according to polyp size in a screening setting.

METHODS

Published studies reporting the distribution of advanced adenomas in asymptomatic screening cohorts according to polyp size were identified by MEDLINE and EMBASE searches. Predefined outputs were the screening rates of advanced adenomas represented by diminutive (< or =5 mm), small (6-9 mm), sub-centimetre (<10 mm) and large (> or =10 mm) polyp sizes.

RESULTS

Data from four studies with 20 562 screening subjects met the primary inclusion criteria. Advanced adenomas were detected in 1155 (5.6%) subjects (95% CI = 5.3-5.9), corresponding to diminutive, small and large polyps in 4.6% (95% CI = 3.4-5.8), 7.9% (95% CI = 6.3-9.4) and 87.5% (95% CI = 86-89.4) of cases respectively. The frequency of advanced lesions among patients whose largest polyp was diminutive, small, sub-centimetre and large in size was 0.9%, 4.9%, 1.7% and 73.5% respectively.

CONCLUSIONS

Based on this systematic review, a 6-mm polyp size threshold for polypectomy referral would identify over 95% of subjects with advanced adenomas, whereas a 10-mm threshold would identify 88% of cases.

Management and long-term follow-up of early stage H. pylori-associated gastric MALT-lymphoma in clinical practice: an Italian, multicentre study

BACKGROUND/AIM

Data on management and long-term follow-up of Helicobacter pylori-associated MALT-lymphoma in clinical practice are scanty. We evaluate the long-term efficacy of H. pylori eradication on low-grade MALT-lymphoma, and the efficacy of further therapies in refractory patients.

METHODS

This study enrolled patients with stages I-II(1) MALT-lymphoma and H. pylori infection. H. pylori eradication was attempted in all patients. Patients with lymphoma persistence or progression following H. pylori treatments received further lymphoma treatments. Both 5-year and disease-free survivals were calculated.

RESULTS

Sixty patients (stage I/II(1): 50/10) were followed up for a median time of 65 months (range 7-156). H. pylori infection was successfully eradicated in 53 (88.3%) patients following three consecutive therapeutic attempts, and lymphoma regressed in 42 (79.2%) of these patients. Sixteen patients received anti-neoplastic treatments due to either lymphoma persistence or progression, and lymphoma was cured in 14 (87.5%) cases. At follow-up, lymphoma relapsed in 13/42 (30.9%) patients within a median time of 19 months (range 3-41), and all but 1 patient were cured with further therapies. Overall, lymphoma regression was achieved in 56 patients (93.3%). The 5-year and disease-free survivals were 94.7% and 74.6%, respectively.

CONCLUSIONS

In clinical practice, a conservative approach with antibiotic eradication seems to be appropriate management for early-stage MALT-lymphoma, with oncologic therapy being reserved for those patients who fail to respond to H. pylori therapy.

Acute abdomen in the elderly. A peripheral general hospital experience

We reviewed our experience on 291 consecutive patients aged over 65 years who were operated on for acute abdomen during the period 2003-2007 at "Santo Spirito" Hospital of Casale Monferrato, a peripheral hospital in the Piedmont region. The mean age of the patients was 78 years and the male/female ratio was 149/142. A total of 126 patients (43%) had one or more associated disease. The most common causes for an emergency operation were mechanical bowel obstruction (45%), hollow viscus perforation (18%) and strangulated hernia (18%). 234 patients (80%) recovered and were free from major complications. The remaining 57 (20%) developed at least one major complication (including death). The 30-days postoperative deaths were 33 (11%). Nonlethal major complications were 24 (8%). The commonest complications were cardio-respiratory. Septic complications were 15. Total reoperations for surgical complications were 5. Mesenteric ischaemia and secondary peritonitis were the most important causes of fatal outcome (respectively 42 and 17% of mortality). We also reported high mortality among patients with peritoneal carcinomatosis (24%). Emergency surgery was relatively safe for the remaining groups of patients, with a complexive mortality ratio of 5.3%. We conclude that "acute abdomen" is still an appreciably frequent cause of death in the older age group. A high level of vigilance and early attention is therefore advocated. Anyway, excluding some severe conditions, the overall success of surgical interventions for abdominal emergency is satisfactory in the majority of older people. About the debated role of peripheral hospitals in the health care system, we conclude that the surgical treatment of the acute abdomen in the elderly is safe and feasible in the peripheral hospitals, and that these hospitals play a determining role in the management of old patients, especially in emergency.

Duplicate breath testing to confirm eradication of Helicobacter pylori: incremental benefit and cost in 419 patients

BACKGROUND

Current standards for establishing a cure of H. pylori infection require two breath tests taken at least 4 weeks apart, to be negative.

AIM

To determine the incremental cost and accuracy of repeating a urea breath test (UBT) in clinical practice.

METHODS

We identified 419 patients with documented Helicobacter pylori infection who received eradication therapy and then had two breath tests, one 4 weeks and the second at least 8 weeks after the completion of treatment. H. pylori infection was documented at baseline by a positive rapid urease test and histology.

RESULTS

In patients with successful eradication of H. pylori infection (n = 317), the mean +/- standard deviation delta over baseline (DOB) value before treatment was 43 +/- 29 ppm. Following treatment, the mean DOB in cured was 0.56 +/- 2.1 ppm at 1 month and was similar to the value obtained at the second breath (0.68 +/- 1; P = 0.39), which was performed 60 +/- 71 days after the first UBT. In patients remaining infected (n = 102), the mean DOB at baseline was 47 +/- 20 ppm. Four weeks after treatment, the DOB was 40 +/- 32 ppm. The second UBT was performed 94 +/- 72 days after the first and the DOB was significantly greater than the first (47 +/- 28; P = 0.040). There was no discordant result between the first breath test and second breath test. At a cost of 30 euros/breath test, the incremental cost of a second breath test was 12 570 euros in this cohort with no incremental clinical benefit.

CONCLUSIONS

A single UBT, 4 weeks after treatment is as effective as two serial breath tests in confirming H. pylori eradication. The incremental cost of the second breath test is very high with no incremental clinical benefit.

Triple therapies plus different probiotics for Helicobacter pylori eradication

The Helicobacter pylori (H. pylori) cure rate following standard triple therapies is decreasing worldwide. Therefore, further approaches aimed to improve standard triple therapy efficacy should be attempted. This prospective, pilot study aimed to evaluate the therapeutic role of either Lactobacillus reuteri (L. reuteri) or a high concentration of probiotics in addition to standard triple therapies for H. pylori eradication. The study enrolled 65 consecutive dyspeptic patients with H. pylori infection. All patients underwent upper endoscopy with gastric biopsies. Patients were assigned to receive one of the following therapies: (a) standard 7-day triple; (b) the same 7-day triple therapy plus L. reuteri supplementation; (c) the same 7-day triple therapy plus a probiotic mixture; and d) a 14-day standard triple therapy plus a probiotic mixture. H. pylori eradication was checked by using a 13C-urea breath test performed 4-6 weeks after treatment. No therapy regimen achieved > 80% eradication rate at both intention-to-treat (ITT) and per protocol (PP) analyses. Although the 14-day therapy plus a probiotic mixture tended to achieve higher eradication rate (71%), no statistically significant difference emerged among the different therapy regimens tested (range: 53-71%). The lowest incidence of side-effects was observed following the 7-day therapy plus L. reuteri (6%) and highest with the 14-day triple therapy plus probiotic mixture (33%), although the difference failed to reach the statistically significance. In conclusion, our data found that 7-14 days triple therapy with or without probiotic supplementation failed to achieved acceptable H. pylori eradication rates.

Cost-effectiveness of capsule endoscopy in screening for colorectal cancer

BACKGROUND AND STUDY AIMS

Capsule endoscopy (Pillcam Colon) has recently shown acceptable accuracy in detecting colonic lesions when compared with colonoscopy. The aim of this analysis is to provide a model to assess the cost and effectiveness of population-based screening for colorectal cancer (CRC) using capsule endoscopy and to compare the cost-effectiveness with that of a colonoscopy screening program.

METHODS

The cost-effectiveness of two screening strategies using colonoscopy or capsule endoscopy were compared by a computer model based on a Markov process. In this model, a hypothetical population of 100,000 individuals aged 50 years and over, undergoes a 10 yearly screening procedure. Different thresholds for postcapsule polypectomy referral were simulated.

RESULTS

At baseline, the incremental cost-effectiveness (compared with no screening) of colonoscopy and capsule endoscopy was $ 16,165 and $ 29,244 per life-year saved, respectively. When equal compliance was simulated, the colonoscopy program was more effective and less costly than a strategy based on capsule endoscopy. When simulating an initial compliance to capsule endoscopy 30% better than colonoscopy, capsule endoscopy became the more effective and more cost-effective option. A 20% better compliance was sufficient when a higher accuracy of capsule endoscopy for polyps was assumed. A 6 mm threshold for polypectomy referral was associated with a substantial cost reduction in the capsule endoscopy program with only a small loss of efficacy.

CONCLUSIONS

The cost-effectiveness of capsule endoscopy depends mainly on its ability to improve compliance to CRC screening.

CT colonography with reduced bowel preparation after incomplete colonoscopy in the elderly

We prospectively assessed the feasibility and acceptance of computerized tomographic colonography (CTC) without bowel cathartic preparation in elderly patients after incomplete colonoscopy. A total of 136 patients underwent CTC without cathartic preparation. The time delay between conventional colonoscopy and CTC ranged between 3 and 20 days, depending on the clinical situation. Before CTC, fecal tagging was achieved by adding diatrizoate meglumine and diatrizoate sodium to regular meals. CTCs were interpreted using a primary two-dimensional (2D) approach and 3D images for further characterization. Patients were interviewed before and 2 weeks after CTC to assess preparation acceptance. CTC was feasible and technically successful in all the 136 patients. Fecal tagging was judged as excellent in 113 (83%) patients and sufficient in 23 (17%). Average CT image interpretation time was 14.8 min. Six (4.4%) cases of colorectal cancer and nine (6.6%) large polyps were detected, as well as 23 (11.3%) extracolonic findings of high clinical importance. No major side effect occurred, although 25% patients reported minor side effects, especially diarrhea. Overall, 76/98 patients replied that they would be willing to repeat the test if necessary. CTC without cathartic preparation is a technically feasible and safe procedure to complete a colonic study in the elderly, prompting its use in clinical practice.

Projected impact of colorectal cancer screening with computerized tomographic colonography on current radiological capacity in Europe

BACKGROUND

The impact of a primary colorectal cancer screening with computerized tomographic colonography on current radiological capacity is unknown. The multispecialty needs for computerized tomographic examinations raise some doubts on the feasibility of a mass colorectal cancer screening with computerized tomographic colonography.

AIM

To assess whether the number of available computerized tomographic units in Europe is adequate to cover population screening with computerized tomographic colonography.

METHODS

A mathematical and a Markov model were, respectively, used to assess the number of computerized tomographic colonography procedures needed to be performed each day in the start-up and in the steady-state phases of a colorectal cancer screening programme in Europe. Such outcome was divided for the total number of computerized tomographic machines aged <10 years estimated to be present in the European hospitals.

RESULTS

At a simulated 30% compliance, 28 760 130 European people would need to be screened by the 3482 available computerized tomographic units in a 5-year start-up period, corresponding to 6.6 CTC/CT unit/day. Assuming a 10-year repetition of computerized tomographic colonography between 50 and 80 years, the number of computerized tomographic colonography needed to be performed in the steady-state period appeared to be 4.3/CT unit/day.

CONCLUSIONS

The current radiological capacity may cover the need for a primary colorectal cancer screening with computerized tomographic colonography in a steady state. On the other hand, a substantial implementation of the current computerized tomographic capacity or a synergistic approach with other techniques seems to be necessary for the start-up period.

Systematic review: Endoscopic dilatation in Crohn's disease

BACKGROUND

Endoscopic dilatation for Crohn's disease has been evaluated only in some small and heterogeneous studies.

AIM

To evaluate any association between the main clinical variables and endoscopic variables and the efficacy and safety of endoscopic dilatation in Crohn's disease.

METHODS

A Medline search regarding pneumatic dilatation in Crohn's disease was performed. Several technical and clinical variables were extracted from each study to build up a descriptive, pool-data analysis. Data on individual patients were extracted from suitable studies to create a simulated population upon which a multivariate statistical analysis was performed.

RESULTS

Thirteen studies enrolling 347 Crohn's disease patients were reviewed. Endoscopic dilatation was mainly applied to postsurgical strictures, being technically successful in 86% of the cases. Long-term clinical efficacy was achieved in 58% of the patients. Mean follow-up was as long as 33 months, corresponding to 800 patient years of follow-up. Major complication rate was 2%, being higher than 10% in two series. At multivariate analysis, a stricture length < or = 4 cm was associated with a surgery-free outcome (OR: 4.01; 95% CI: 1.16-13.8; P < 0.028).

CONCLUSIONS

Endoscopic dilatation is an effective and safe treatment for short strictures caused by Crohn's disease, impacting substantially on the natural history of these patients.

Levofloxacin-based triple therapy for Helicobacter pylori re-treatment: role of bacterial resistance

BACKGROUND

First-line Helicobacter pylori therapy fails in more than 20% of patients. Quadruple therapy is the suggested second-line therapy, but bismuth salts are not anymore available worldwide. This study aimed to assess the efficacy of a levofloxacin-amoxycillin triple therapy as a second-line treatment, and the role of primary levofloxacin resistance.

METHODS

Forty patients, in whom first treatment with either standard 10-day triple or sequential therapy had failed, received 10-day triple therapy with rabeprazole (20mg b.d.), levofloxacin (250mg b.d.), and amoxycillin (1g b.d.). Cure rates were evaluated by the (13)C-urea breath test. Primary levofloxacin resistance was detected by culture.

RESULTS

Bacterial culture was available in 33 (82.5%) out 40 patients, and primary levofloxacin resistance was detected in 10 (30.3%) patients. Overall, 33 of 40 patients accepted to participate in this study, and all returned for follow-up after therapy. Compliance to the therapy was safe except 1 patient only who stopped earlier the treatment due to side effects (oral candidiasis). H. pylori infection was eradicated in 24 patients, accounting for a 72.7% (95% CI: 57-88) eradication rate at both intention-to-treat and per protocol analyses. The eradication rate was higher in patients harbouring levofloxacin-susceptible than resistant strains (75% versus 33.3%; P=0.074).

CONCLUSIONS

The eradication rate achieved by a levofloxacin-based re-treatment seems to be decreasing, and its efficacy is reduced in presence of levofloxacin resistance.

Tumor necrosis factor alpha in ulcerative colitis and diverticular disease associated colitis

Conventional treatment of moderate-severe ulcerative colitis (UC) has resulted in only a limited therapeutic benefit. Advancing knowledge of UC pathogenesis and recent advances in biotechnology have led to the development of biological agents that selectively target individual inflammatory pathways. In particular, the role of tumor necrosis factor alpha (TNF-alpha) in UC pathogenesis has been clarified by serological and immunohistochemical studies in humans and by experimental models. Clinical efficacy of anti-TNF-alpha therapy with infliximab has been assessed in two large controlled trials, showing a good compromise between therapeutic gain and safety. The aim of this review is to provide an insight into the role of TNF-alpha and anti-TNF-alpha therapy in patients with UC and diverticular disease associated colitis.