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Background: The main goal in the treatment of ulcerative colitis (UC) is to achieve mucosal healing. Despite being unvalidated, the most widely used scoring system is the Mayo endoscopic subscore (MES). However, the recently established and validated Ulcerative Colitis Endoscopic Index of Severity (UCEIS) represents an interesting alternative method in assessing endoscopic disease activity. Objective: Due to a lack of reliable prognostic factors, the aim of this study was to investigate the diagnostic accuracy of the UCEIS and the MES, in predicting response to biological therapy and the need for colectomy. Methods: We conducted a retrospective, uncontrolled, single-center study on UC patients with endoscopically active disease even with concomitant conventional and/or biological therapy, who had already started or had been changed a biological treatment. Results: Sixty-one UC patients were enrolled. At baseline, 71% were naive to biological therapies and 41% had an extensive colitis. At control time (median time of 11.5 months), MES and UCEIS scores significantly decreased from those at baseline (from 2.6 to 1.8 and 5 to 3.2, respectively, p < 0.001). UCEIS, but not MES, was found to be significantly associated with unresponsiveness to therapy (p = 0.040). Moreover, when UCEIS was ≥7, all patients underwent colectomy after a median time of 5 months (p < 0.001). Conclusion: UCEIS may be superior to MES because of its accuracy and predictive role. Therefore, UCEIS should be considered for use in daily clinical practice.

Gut microbiota is involved in gastrointestinal carcinogenesis. Also, it modulates the activity, efficacy and toxicity of several chemotherapy agents, such as gemcitabine, cyclophosphamide, irinotecan, cisplatin and 5-Fluorouracil, and target therapy, such as tyrosine kinase inhibitors. More recently, accumulating data suggest that the composition of gut microbiota may also affect efficacy and toxicity of cancer immunotherapy. Therefore, the manipulation of gut microbiota through antibiotics, probiotics, prebiotics or fecal transplantation has been investigating with the aim to improve efficacy and mitigate toxicity of anticancer drugs.

Study Objective To evaluate the incidence, risk factors, and treatment of colorectal anastomotic stenosis in patients who undergo rectosigmoid resection for deep infiltrating endometriosis (DIE). Design Retrospective analysis of a prospective database (Canadian Task Force classification III). Setting Public medical center. Patients All women who underwent laparoscopic rectosigmoid resections for DIE at our hospital between January 2002 and December 2016. Intervention All patients were evaluated clinically and endoscopically at 1 month and 3 months after bowel resection. Stenosis was defined as a lack of passage through the anastomosis of a 12-mm proctoscope. Symptomatic stenosis was defined as the presence of endoscopically confirmed stricture accompanied by at least 2 of the following symptoms: constipation, need to push, tenesmus, and ribbon stools. Only patients with symptomatic stenosis were studied. Demographic data, surgical techniques, and postoperative complications were recorded prospectively. Treatments and outcomes of anastomotic symptomatic strictures were analyzed. Measurements and Main Results A total of 1643 patients underwent laparoscopic rectosigmoid resection at our hospital between January 2002 and December 2016. Among these, 104 patients (6.3%) presented with symptomatic anastomotic stenosis. The median patient age was 27 years (range, 23–44 years), and the median interval between diagnosis and the onset of symptomatic stenosis was 57 days (range, 21–64 days). The only statistically significant predictors of anastomotic stenosis were the presence of ileostomy (p = .01) and previous pelvic surgery (p = .002). Treatment of choice was always conservative. Of the 104 patients in the study cohort, 90 (86.5%) underwent 3 endoscopic dilatations. No patient required reoperation. Conclusion The anastomotic stricture is a recognized complication in patients following intestinal resection for DIE, and protective ileostomy is the sole modifiable factor related to anastomotic stenosis. Endoscopic dilatation is a valid option to treat this complication.

Background and Aim: Contrast harmonic endoscopic ultrasound (CH-EUS) was recently introduced to clinical practice; its reproducibility among endosonographers is unknown. Our aim was to assess the interobserver agreement (IA) in CH-EUS. Methods: Fifteen endosonographers (eight experienced and seven non-experienced) from 11 Italian EUS centers evaluated 80 video-cases (40 solid pancreatic lesions, 20 pancreatic cystic lesions and 20 submucosal lesions) of CH-EUS, according to the degree of enhance- ment, the pattern of distribution and the washout of the contrast agent. IAwithin each group and between the two groups of observers was assessed with the Fleiss kappa statistic. Results: Overall IAwas moderate for the uptake and fair for the pattern of distribution and the washout. In solid pancreatic lesions, IA was moderate for the uptake and fair for the pattern and the washout. In cystic pancreatic lesions, IA was uniformly moderate for the assessment of uptake, slight for the pattern and fair for the washout. In submucosal tumors, IA was substantial for the uptake, slight for the pattern and fair for the washout. Non- experienced endosonographers demonstrated, in most cases, comparable IAwith the expe- rienced ones. Conclusions: Interobserver agreement among endosonographers for CH EUS was satis- factory. In particular, overall IA varied from slight to substantial, being fair in the majority of cases. Inherent structural features of the lesions, as well as technical differences between the variables assessed, could have accounted for the fluctuation of the results. Outcomes of IA were reproducible between experienced and non-experienced endosonographers.

Quand s’instaure un etat d’hypertension portale, des circulations collaterales entre le systeme porte et le systeme cave se forment ou s’ouvrent. Du point de vue clinique, les plus importantes sont celles qui impliquent le secteur gastro-intestinal, parce qu’elles peuvent provoquer la dilatation du plexus sous-muqueux avec formation de varices endoluminales. Les varices peuvent se trouver sur tous secteurs du tractus gastro-intestinal (oesophage, estomac, duodenum, ileon, colon, rectum), mais les varices gastro-oesophagiennes s’observent plus frequemment et en cas de rupture, elles peuvent provoquer de graves hemorragies. L’hemorragie de varices oesophagiennes represente encore aujourd’hui une des plus graves complications de la cirrhose hepatique et un defi toujour renouvele pour l’endoscopiste. Malgre l’introduction de nouveaux moyens diagnostiques et de nouvelles therapies, la mortalite au premier episode de saignement reste encore tres ⫑evee (30%–40%). Ceci est lie non seulement a l’entite de l’hemorragie et a la vitesse de son controle mais egalement au stade d’insuffisance hepatique et a l’apparition de complications cardio-pulmonaire, renales, infectieuses et surtout hemorragiques. L’examen endoscopique, s’il est conduit de maniere correcte, represente la meilleure technique pour le diagnostic, la classification et la therapie aussi bien en premiere intention qu’en urgence.

To establish a correct preoperative differential diagnosis between gastric lymphoma and cancer is essential but can be difficult as endoscopic biopsies can sometimes provide a low diagnostic yield. By EUS, infiltrative carcinoma tends to show a vertical growth in the gastric wall, while lymphoma tends to show mainly a horizontal extension. EUS provides an accurate staging of gastric lymphoma, showing the exact level of infiltration and the presence of perigastric lymph nodes, thus the physician can obtain an accurate prognosis for each patient and select the best form of treatment accordingly. The response to chemoradiotherapy can also be investigated very accurately by EUS. Large gastric folds are seen in a great number of benign and malignant conditions. Diagnosis represents a clinical challenge because etiology may be extremely varied and standard biopsies are often inconclusive. Different diseases show different levels of infiltration of the gastric wall, thus a characteristic echo-pattern helps for the differential diagnosis. Endosonography, used always in combination with biopsy, allows to rule out malignancies and to select the most appropriate treatment for each patient (medical or surgical).

Le lymphome gastrique primaire represente 2 a 8 % de la totalite des lesions malignes de l’estomac et son incidence semble s’accroitre. Le lymphome gastrique a un meilleur pronostic que le carcinome de l’estomac compte tenu de sa sensibilite a la radiotherapie (RT) ou de la chimiotherapie (CT), d’ou l’importance de poser un diagnostic preoperatoire correct entre lymphome gastrique et cancer meme si generalement un tel diagnostic est considere comme difficile.

Platinum-based neoadjuvant therapy is the standard treatment for esophageal cancer (EC). At present, no reliable response markers exist, and patient therapeutic outcome is variable and very often unpredictable. The aim of this study was to understand the contribution of host constitutive DNA polymorphisms in discriminating between responder and nonresponder patients. DNA collected from 120 EC patients treated with platinum-based neoadjuvant chemotherapy was analyzed using drug metabolism enzymes and transporters (DMET) array platform that interrogates polymorphisms in 225 genes of drug metabolism and disposition. Four gene variants of DNA repair machinery, 2 in ERCC1 (rs11615; rs3212986), and 2 in XPD (rs1799793; rs13181) were also studied. Association analysis was performed with pTest software and corrected by permutation test. Predictive models of response were created using the receiver-operating characteristics curve approach and adjusted by the bootstrap procedure. Sixteen single nucleotide polymorphisms (SNPs) of the DMET array resulted significantly associated with either good or poor response; no association was found for the 4 variants mapping in DNA repair genes. The predictive power of 5 DMET SNPs mapping in ABCC2 , ABCC3 , CYP2A6 , PPARG , and SLC7A8 genes was greater than that of clinical factors alone (area under the curve [AUC] = 0.74 vs 0.62). Interestingly, their combination with the clinical variables significantly increased the predictivity of the model (AUC = 0.78 vs 0.62, P = 0.0016). In conclusion, we identified a genetic signature of response to platinum-based neoadjuvant chemotherapy in EC patients. Our results also disclose the potential benefit of combining genetic and clinical variables for personalized EC management.

AimTo test the contribution of programmed cell death 4 (PDCD4) tumour suppressor gene in Barrett's carcinogenesis.MethodsPDCD4 immunohistochemical expression was assessed in 88 biopsy samples obtained from histologically proven long-segment Barrett's mucosa (BM; 25 non-intestinal columnar metaplasia, 25 intestinal metaplasia (IM), 16 low-grade intraepithelial neoplasia (LG-IEN), 12 high-grade IEN (HG-IEN) and 10 Barrett's adenocarcinoma (BAc)). As controls, 25 additional samples of native oesophageal mucosa (N) were obtained from patients with dyspepsia. To further support the data, the expression levels of miR-21, an important PDCD4 expression regulator, in 14 N, 5 HG-IEN and 11 BAc samples were determined by quantitative real-time PCR analysis.ResultsPDCD4 immunostaining decreased progressively and significantly with the progression of the phenotypic changes occurring during Barrett's carcinogenesis (pPDCD4 dysregulation.ConclusionsThese data support a significant role for PDCD4 downregulation in the progression of BM to BAc, and confirm miR-21 as a negative regulator of PDCD4 in vivo. Further efforts are needed to validate PDCD4 as a potential prognostic marker in patients with Barrett's oesophagus.

There is no clear consensus concerning the best endoscopic treatment of benign refractory esophageal strictures due to caustic ingestion. Different procedures are currently used: frequent multiple dilations, retrievable self-expanding stent, nasogastric intubation and surgery. We describe a new technique to fix a suspended esophageal silicone prosthesis to the neck in benign esophageal strictures; this permits us to avoid the frequent risk of migration of the expandable metallic or plastic stents. Under general anesthesia a rigid esophagoscope was placed in the patient's hypopharynx. Using transillumination from the optical device, the patient's neck was pierced with a needle. A n.0 monofilament surgical wire was pushed into the needle, grasped by a standard foreign body forceps through the esophagoscope and pulled out of the mouth (as in percutaneous endoscopic gastrostomy procedure). After tying the proximal end of the silicone prosthesis with the wire, it was placed through the strictures under endoscopic view. This procedure was successfully utilized in four patients suffering from benign refractory esophageal strictures due to caustic ingestion. The prosthesis and its suspension from the neck were well-tolerated until removal (mean duration 4 months). A postoperative transitory myositis was diagnosed in only one patient. One of the most frequent complications of esophageal prostheses in refractory esophageal strictures due to caustic ingestion is distal migration. Different solutions were proposed. For example the suspension of a wire coming from the nose and then fixed behind the ear. This solution is not considered optimal because of patient complaints and moreover the aesthetic aspect is compromised. The procedure we utilized in four patients utilized the setting of a silicone tube hanging from the neck in a way similar to that of endoscopic pharyngostomy. This solution is a valid alternative both for quality of life and for functional results.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, but they have been rarely reported in the esophagus. The authors present the case of an esophageal GIST and discuss the diagnostic course and therapeutic options, as currently reported in the literature.

Colitis cystica profunda is a rare intestinal lesion. Because of its clinical expression (rectorrhagia, mucorrhea and abdominal pain) and the way it appears to current imaging techniques this disease presents features which can be associated with colon neoplasm. Its diagnosis has to be confirmed histologically, and its etiology remains unclear. The following is a case report of colitis cystica profunda recurring 20 years after a first episode in a white woman, who had had an anterior resection of the sigmoid colon and upper rectum to deal with a colitis cystica profunda-induced stenosis of the sigmoid colon and at 41 underwent the transanal removal of a polypoid lesion. A review of 20 cases in the literature showed that colitis cystica profunda has a predilection for the male and generally affects the medial and lower rectum and the sigmoid colon. The literature also confirmed the association with ulcerative rectocolitis, Crohn's disease and rectal prolapse. The type of treatment varies from surgical, medical, and endoscopic to no treatment at all.

Mucosectomy involves resection of a digestive wall fragment that frequently removes a part or even all of the submucosal mass. The single-band mucosectomy technique was used to remove a granular cell tumor (GCT) of the esophagus. Only 3% of GCTs, which are relatively uncommon neoplasms, arise in the esophagus. Ultrasonography has allowed for more frequent recognition and better definition of this disease. Until recently, surgical resection of the esophagus has been the only treatment alternative to endoscopic surveillance. Endoscopic techniques such as mucosal resection (EMR), laser, and argon plasma have been proposed as safe and effective alternatives to surgery. However, to date, only a few reports of these endoscopic techniques have been published. This study aimed to evaluate the safety and feasibility of single-band mucosectomy for removing a GCT of the esophagus. Six patients (1 man and 5 women; mean age, 45 years) with a GCT were studied between January 2000 and May 2004. They underwent EMR after endoscopic ultrasonography. The EMR was performed with a diathermic loop after injection of saline solution into the esophageal wall. Only one session was necessary for removal of the tumor from all 6 patients, and no complication was observed. During a mean clinical endoscopic follow-up period of 36 months, no recurrences, scars, or stenoses were observed. These findings show EMR to be a safe and effective technique that allows complete removal of GCTs. Furthermore, this technique provides tissue for a definitive pathologic diagnosis, which laser and argon plasma do not provide. We recommend EMR as the treatment of choice for GCTs after an accurate ultrasonographic evaluation.

Large gastric folds are seen in a great number of benign and malignant conditions. Diagnosis is a clinical challenge because the etiology may be extremely varied and standard biopsies are often inconclusive. The gastric wall is considered thickened at endosonography when it is more than 3.6 mm in width. Different diseases show different levels of infiltration of the gastric wall. When abnormalities involve the second layer only, benign conditions can be considered and standard endoscopic biopsies are often diagnostic. When abnormalities involve layers two and three, different diseases can be suspected, including Helicobacter pylori infection and lymphoma; in this case large-particle biopsy should be considered. When abnormalities involve layer four, malignancy should be strongly suspected even if standard or large-particle biopsies are negative. Endosonography, always in combination with fine-needle or guillotine-needle biopsy, should be able to rule out malignancies and to select the most appropriate treatment for each patient.

Endoscopic ultrasonography (EUS) is nowadays a clinically relevant technology and its findings can have a major impact on patient management. This technique is currently indicated for staging digestive cancers, assessment of submucosal tumors, diagnosis of intestinal wall infiltrative diseases, common bile-duct stones and gut neuroendocrine tumors. As far as neoplasms are concerned, EUS appears to be a reliable and safe technique, thus making the physician able to plan either an aggressive surgical treatment, or a conservative palliative therapy. This is of the utmost importance in order to optimize medical-related costs, and to make the best therapeutic decision for each individual patient. EUS is also helpful in monitoring the course of a disease, as it is simple and virtually without complications. When EUS findings are not sufficient for a complete diagnosis, it is now possible to perform an EUS-guided fine-needle biopsy, which can allow a cytological diagnosis. Finally, some therapeutic endosonography-guided procedures are being increasingly adopted, such as cystoenterostomy, celiac plexus neurolysis, cholangio-pancreatography and selective injection of botulinum toxin in the muscle layer of the lower esophageal sphincter.

Objectives: The aim of the present study was to evaluate the efficacy and the safety of a short-term regimen (weekend therapy) in the cure of Helicobacter pylori infection and to analyze the factors that may influence the success of the treatment. Methods: Seventy-one patients with gastric colonization by a tinidazole sensitive H. pylori strain (34 duodenal ulcer and 37 nonulcer dyspepsia) received omeprazole 40 mg o.m. for 7 days (from Monday to Sunday) and bismuth 240 mg q.i.d. + amoxicillin 1000 mg/q.i.d. + tinidazole 500 mg q.i.d. for only 2 days (Saturday and Sunday). Endoscopy, histology, culture, urease test, and susceptibility studies were done at entry and 30 days after treatment. Results: Successful eradication was obtained in 84% of patients. The percentage of eradication was higher in duodenal ulcer patients (94%) than in those with nonulcer dyspepsia (74%; p < 0.05), and in patients who received the treatment during hot weather (94%) than in those who received the treatment during cold weather (74%; p < 0.05). Side-effects were induced by the treatment in 17% of patients, and these were all not severe, self-limiting, short-lasting, and did not require specific treatment. Conclusions: These data suggested that weekend therapy with high doses of drugs represents an effective, safe, and inexpensive therapeutic approach for the treatment of H. pylori infection, particularly in patients with duodenal ulcer. Furthermore, they also confirm the relevant role that short-term treatments may play in the therapeutic approach to H. pylori infection, and highlight some important aspects influencing short-term schedules.

Precise staging of reflux esophagitis is very important for therapeutic decisions; in fact, chronic gastroesophageal reflux may cause transmural inflammation that leads to fibrosis with loss of esophageal wall compliance. In reflux esophagitis, endoscopic stating is limited to mucosal injury, while endoscopic ultrasonography (EUS) is able to visualize changes in the layer structure and localized or diffuse thickenings of the esophageal wall. In order to evaluate the usefulness of EUS in reflux esophagitis, a prospective study of 31 patients and ten normal subjects was performed. Endoscopic reflux esophagitis was staged as: E1 (erythema, n = 7), E2 (erosions, n = 13), E3 (ulcers, n = 11). EUS findings were recorded and evaluated at five different levels, starting from the gastroesophageal junction, using a quantitative method, the center line method. With this method, the sectorial and mean thickness, and area were calculated for each level. There was a significant difference between patients with reflux esophagitis and normal subjects in our study. E3 patients showed a significant upward involvement of the wall far from the visible lesions. Mild esophagitis may also cause esophageal wall thickening, involving even the entire wall. There was no correlation between the onset time of symptoms and the degree of thickening. In conclusion, EUS seems to be an important supplement to endoscopy in staging reflux esophagitis, as the progression of the inflammation is not related to the endoscopic findings.

respectively. Both items were associated with inadequate bowel cleansing at univariate analysis. Conclusions: This study identified multiple factors affecting the quality of colonic preparation, some of which can be modified to achieve a higher degree of bowel cleansing. Important non-modifiable factors may be valuable in identifying subjects for whom more aggressive cleansing protocols should be considered.