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Background: The most appropriate endo‐therapeutic approach to biliary anastomotic strictures is yet to be defined. Aim: To retrospectively report on the endo‐therapy of duct‐to‐duct anastomotic strictures during 2013 in Italy. Methods: Data were collected from 16 Endoscopy Units at the Italian Liver Transplantation Centers (BASALT study group). Results: Complete endo‐therapy and follow‐up data are available for 181 patients: 101 treated with plastic multistenting, 26 with fully covered self‐expandable metal stenting and 54 with single stenting. Radiological success was achieved for 145 patients (80%), that is, 88% of plastic multistenting, 88% of self‐expandable metal stenting and 61% of single stenting (P < 0.001 vs plastic multistenting; P < 0.05 vs self‐expandable metal stenting). After first‐line endo‐therapy failure, the patients underwent a second‐line endo‐therapy with plastic multistenting for 25%, fully covered self‐expandable metal stenting for 53% and single stenting for 22% of cases, and radiological success was achieved for 84%, that is, 100%, 85% and 63% with plastic multistenting, self‐expandable metal stenting and single stenting (P < 0.05 vs plastic multistenting or self‐expandable metal stenting) respectively. Procedure‐related complications occurred in 7.8% of endoscopic retrograde cholangiopancreatographies. Overall, clinical success was achieved in 87% of patients after a median follow‐up of 25 months. Conclusion: Plastic multistenting is confirmed as the preferred first‐line treatment, while fully covered self‐expandable metal stenting as rescue option for biliary anastomotic strictures. Single stenting has sub‐optimal results and should be abandoned. See Editorial on Page 1197 [ABSTRACT FROM AUTHOR]

Aims: To measure patients' satisfaction after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stones in a large number of unselected endoscopy units. Methods: A prospective study using a questionnaire (Group Health Association of America—9 [GHAA-9], modified) was administered 24 h and 30 days after the procedure. Patients undergoing endoscopy for biliary stones for the first time were enrolled in a large number of endoscopy units, regardless of their size and workload. Results: In all, 700 patients were enrolled in 15 units. A high proportion of patients expressed satisfaction (80%). Satisfaction was less extensive for pain control and the quality of information provided before the procedure. There were no differences in the replies to questionnaires at 24 h and 30 days. Conclusion: It is feasible to record patients' satisfaction and in this series most patients were very satisfied. Criticisms concerned pain control and explanations provided before the procedure. [ABSTRACT FROM AUTHOR]

Background: The management of extrahepatic portal vein obstruction (EHPVO) in children is controversial. We report our experience with a prospective evaluation of a stepwise protocol based on severity of portal hypertension and feasibility of mesoportal bypass (MPB)., Methods: After diagnosis, children with EHPVO underwent surveillance endoscopies and received nonselective β-blockers (NSBBs) or endoscopic variceal obliteration (EVO) when large varices were detected. In patients who failed NSBBs and EVO, we considered MPB as first-line and shunts or transjugular intrahepatic portosystemic shunt (TIPS) as second-line options., Results: Sixty-five children, median age 12.5 (range 1.6-25.8), whose age at diagnosis was 3.5 (0.2-17.5) years, were referred to our unit. Forty-three (66%) had a neonatal illness, 36 (55%) an umbilical vein catheterisation. Thirty-two (49%) presented with bleeding at a median age of 3.8 years (0.5-15.5); during an 8.4-year follow-up period (1-16), 43 (66%) had a bleeding episode, 52 (80%) were started on NSBBs, 55 (85%) required EVO, and 33 (51%) required surgery or TIPS. The Rex recessus was patent in 24 of 54 (44%), negatively affected by a history of umbilical catheterisation (P = 0.01). Thirty-four (53%) patients underwent a major procedure: MPB (13), proximal splenorenal (13), distal splenorenal (2), mesocaval shunt (3), TIPS (2), and OLT (1). At the last follow-up, 2 patients died, 53 of 57 (93%) are alive with bleeding control, 27 of 33 (82%) have a patent conduit., Conclusions: Children with EHPVO have a high rate of bleeding episodes early in life. A stepwise approach comprising of medical, endoscopic, and surgical options provided excellent survival and bleeding control in this population.

Background: Self-expanding metal stents (SEMSs) are used to treat malignant stenosis of the gastrointestinal (GI) tract, as a safe, feasible, and minimally invasive option for reestablishing luminal patency. However, the literature offers scant prospective data on the clinical outcome of these patients., Aim: To assess the technical success, complications, and clinical outcomes of patients with a SEMS placed for malignant upper and lower GI obstruction., Patients and Methods: A cohort of 110 patients with clinical symptoms related to malignant stenosis of the upper and lower GI tract were prospectively enrolled and SEMSs were placed endoscopically in 9 endoscopy centers. The patients were followed up and survival, oral intake, stool canalization, and late complications were recorded on days 30, 90, and 180., Results: Overall, 110 patients, 38 (34.5%) with upper and 72 (65.5%) with lower GI obstruction were examined. The procedure was successful in 102 (92.7%). There were 5 early complications (<96 h) (4.5%). Late complications (>96 h) occurred in 6 patients (6.3%). Median survival after stenting was 90 days (q1 30; q3 120). Placing the SEMS enabled 79.4%, 90.9%, and 100% of the patients to resume an oral diet at 30, 90, and 180 days, respectively. All patients had stool canalization until death., Conclusions: Endoscopic stenting is an effective and safe procedure for malignant luminal obstruction of the GI tract, with good clinical outcomes in patients whose survival is unfortunately short.

Background and Aim: Inflammatory bowel diseases (IBD) commonly affect women during the reproductive years. The aim of the present study was to evaluate the reproductive histories of patients with ulcerative colitis (UC) and Crohn's disease (CD) considering pregnancies occurring before and after the diagnosis., Method: Case-control study evaluating IBD patients, interviewed by questionnaire about outcome of pregnancy and course of disease., Results: A total of 502 pregnancies from 199 patients in the prediagnosis group and 121 pregnancies from 90 patients in the post-diagnosis group were respectively compared with 996 and 204 pregnancies recorded in a control population. In prediagnosis pregnancies, CD was associated with increased risk of preterm delivery (odds ratio [OR] 4.62, 95% confidence interval [CI] 2.77-7.73; P < 0.001 vs controls and OR 3.52, 95% CI 1.75-7.07; P < 0.001 vs UC) and lower birthweight (P < 0.001 vs UC and controls). In post-diagnosis pregnancies, the rate of live births was lower, but not statistically significant in IBD (OR 0.22, 95% CI 0.04-1.25; P = 0.08) and the birthweight was significantly lower in CD than in UC (P < 0.03) and in controls (P < 0.02). In post-diagnosis pregnancies, a higher incidence of congenital abnormalities was found in IBD patients (5.5% vs 0.0%). The spontaneous abortion rate and therapeutic abortions were significantly higher in post than in prediagnosis pregnancies. Neither disease activity at conception nor treatment appeared to influence the outcome of pregnancy., Conclusions: CD in the preclinical phase has some influence on pregnancy. In patients with IBD our data suggest that conception should not be discouraged. However, because of a modest increase in mild congenital abnormalities and abortions rates, pregnancy in IBD patients should be closely monitored.

Objective: Barrett's esophagus (BE) is a premalignant condition for which regular endoscopic follow-up is usually advised. We evaluated the incidence of esophageal adenocarcinoma (AC) in patients with BE and the impact of endoscopic surveillance on mortality from AC., Methods: A cohort of newly diagnosed BE patients was studied prospectively. Endoscopic and histological surveillance was recommended every 2 yr. Follow-up status was determined from hospital and registry office records and telephone calls to the patients., Results: From 1987 to 1997, BE was diagnosed in 177 patients. We excluded three with high-grade dysplasia (HGD) at the time of enrollment. Follow-up was complete in 166 patients (135 male, 31 female). The mean length of endoscopic follow-up was 5.5 yr (range 0.5-13.3). Low-grade dysplasia (LGD) was present initially in 16 patients (9.6%) and found during follow-up in another 24 patients. However, in 75% of cases, LGD was not confirmed on later biopsies. HGD was found during surveillance in three patients (1.8%), one with simultaneous AC; two with HGD developed AC later. AC was detected in five male patients during surveillance. The incidence of AC was 1/220 (5/1100) patient-years of total follow-up, or 1/183.6 (5/918) patient-years in subjects undergoing endoscopy. Four AC patients died, and one was alive with advanced-stage tumor. The mean number of endoscopies performed for surveillance, rather than for symptoms, was 2.4 (range 1-10) per patient. During the follow-up years the cohort had a total of 528 examinations and more than 4000 biopsies., Conclusions: The incidence of AC in BE is low, confirming recent data from the literature reporting an overestimation of cancer risk in these patients. In our patient cohort, surveillance involved a large expenditure of effort but did not prevent any cancer deaths. The benefit of surveillance remains uncertain.

The role of cigarette smoking and diabetes mellitus as risk factors for exocrine pancreatic cancer (PC) was investigated in a hospital based case-control study. Current smokers were at increased risk for PC (OR = 2.36, 95% CI 1.53-3.63): the magnitude of the risk was related to the lifetime amount of smoking (chi2(trend) = 17.00; P < 0.0001). Among former smokers, after 15 years from ceasing smoking, the risk for PC dropped to the level of a lifetime non-smoker, whichever the lifetime smoking amount. Diabetes was associated with a 2.89-fold increased risk for PC (95% CI 1.71-4.86): the risk was 4.76 (95% CI 1.99-11.53) for diabetes diagnosed up to 2 years before the diagnosis of PC and dropped to 2.07 (95% CI 1.02-4.20) for diabetes diagnosed more than 5 years before PC. The risk for PC was estimated according to the treatment used to control diabetes: it was 6.49 (95% CI 2.28-18.48) for insulin treated diabetes and 2.12 (95% CI 1.16-3.87) for diabetes treated with oral hypoglycemic drugs. The risk of PC for diabetes treated for more than 5 years before the diagnosis of PC was 6.21 (95% CI 1.61-23.96) for patients treated with insulin and 1.21 (95% CI 0.50-2.92) for those treated with oral hypoglycemic drugs: the type of treatment needed to control the disease may discriminate between the diabetes that represents a consequence of cancer from the diabetes that could represent an etiological co-factor. More studies are needed to clarify whether long-lasting insulin-treated diabetes is an etiological co-factor in PC.

Barrett's esophagus (BE) is an acquired disorder due to chronic gastroesophageal reflux. Environmental factors seem to play an important role in the pathogenesis of BE, especially in Western society. A multicenter case-control study was carried out between February 1995 and April 1999 in 8 Italian Departments of Gastroenterology gathered in a study group (GOSPE), in order to analyze the influence of some individual characteristics and life-style habits on the occurrence of BE. Three groups of patients were studied: 149 patients with BE, 143 patients with esophagitis (E) and 308 hospital controls (C) with acute, non-neoplastic, non-gastroenterological conditions. The diagnosis of BE was based on endoscopy and histology. E was defined by the Savary classification (grade I-III). Data collection was performed by using a questionnaire that focused on smoking, coffee and alcohol consumption, medical history, drugs history, gastroesophageal reflux disease (GERD) symptoms (heartburn, regurgitation) and socio-economic status. Multivariate analysis showed that the frequency of weekly GERD symptoms was significantly associated with both BE and E (p<0.0001), such as the presence of hiatal hernia (p< or =0.001). Ulcer was significantly associated with BE (p=0.001). Among patients with E, the risk was directly related to spirits consumption (p=0.03). Patients with GERD symptoms that lasted more than 13 years were more likely to have BE than E (p=0.01). In conclusion, results from our study point out that long-standing GERD symptoms, hiatal hernia and possibly alcohol consumption are risk factors in the development of the BE and E., (Copyright 2002 Wiley-Liss, Inc.)