Alfredo Rossi

Prophylactic sclerotherapy in high-risk cirrhotics selected by endoscopic criteria: A multicenter randomized controlled trial

Controlled trials of sclerotherapy for the prevention of the first variceal hemorrhage in cirrhotics have given conflicting results. In the present study, 106 cirrhotics were randomized to sclerotherapy (55 patients) or control group (51 patients). Admission criteria were no history of previous variceal bleeding and the presence of high-risk varices, i.e., a variceal score less than or equal to 0 according to Beppu et al. Sclerotherapy sessions were performed at time zero, 7 days, 30 days, and then monthly until eradication. Follow-up endoscopies were performed at 6-month intervals thereafter. Control patients underwent repeat endoscopy at 6-month intervals. Bleeding episodes were treated by sclerotherapy in both groups, whenever possible. Mean follow-up was 24 months. Analysis of the results was performed by the intention-to-treat method. Variceal bleeding occurred in 19 sclerotherapy patients (34.5%) and in 17 controls (35.4%, P = NS). Overall mortality was 34.5% in sclerotherapy patients and 50% in controls (P = NS). Seven of the 19 sclerotherapy patients (36.8%) and 11 of the 17 controls (64.7%) who bled died of hemorrhage (P less than 0.05, log-linear model). It is concluded that prophylactic sclerotherapy does not reduce the incidence of first variceal bleeding in cirrhotics. However, there seems to be a trend toward a lower bleeding-related mortality in sclerotherapy patients than in controls.

Long-term efficacy of endoscopic stenting in patients with stricture of the biliary anastomosis after orthotopic liver transplantation

BACKGROUND AND STUDY AIMS The choledocho-choledochostomy (CCS) stricture is one of the most frequent complications occurring after liver transplantation. Endoscopic retrograde cholangiography (ERCP) is the most sensitive method used to define the presence and narrowness of the stricture. Endoscopic stenting of the strictured anastomosis could provide an effective alternative to the surgical intervention. PATIENTS AND METHOD ERCP was performed in 36 of 210 patients with liver transplantation and acute cholestasis or jaundice: in 15 cases biliary anastomotic stricture was found. These patients were endoscopically treated by long-term stenting of the common bile duct (CBD) (1 year) and followed up for more than 12 months after stent removal. RESULTS In all cases the stenting procedure resolved the biliary obstruction syndrome within 7 days. At the end of the stenting period the CCS was dilated enough to allow adequate bile flow and absence of cholestasis. Moreover, in most patients (10) the anastomosis was kept patient for more than 1 year after stent removal, whereas only two patients had stricture recurrence and needed endoscopic restenting. Four patients dropped out of the study, respectively because of liver rejection (two), acute liver failure (one) and myocardial infarction (one). One patient who developed a stone of the transplanted CBD underwent surgical intervention. CONCLUSIONS According to our data, the endoscopic stenting of the CBD might be considered as the first choice procedure in the setting of the biliary anastomotic strictures occurring after liver transplantation. It has proved to be safe and effective, avoiding the need for more invasive surgery, which in any case should be considered for nonresponsive patients.

Update on management of caustic and foreign body ingestion in children

The following recommendations for management of caustic and foreign body ingestion in children have been developed following a multicentre study performed by the Italian Society for Paediatric Gastroenterology, Hepatology and Nutrition (SIGENP). They are principally addressed to medical professionals involved in casualty. Because there is paucity of good quality clinical trials in children on this topic, many of the recommendations are currently extrapolated from adult experiences or based on experts opinions. The document represents a level 2 to 5 degree of evidence (according to the Oxford Centre for Evidence-based Medicine Levels of Evidence), gathered from clinical experience, recent studies, and expert reports discussed during a consensus conference of the Endoscopic Section of the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition. This working group comprises paediatricians, endoscopists, paediatric surgeons, toxicologists, and ENT surgeons, who are all actively involved in the management of these children. Recommendations are intended to serve as an aid to clinical judgement, not to replace it and therefore do not provide answers to every clinical question; nor does adherence to them ensure a successful outcome in every case. The ultimate decision on the clinical management of an individual patient will always depend on the specific clinical circumstances of the patient, and on the clinical judgement of the health care team.

MANAGEMENT OF PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE: A LONG-TERM, FOLLOW-UP STUDY

Abstract Although the effect of short-term treatment on gastroesophageal reflux disease (GERD) has been studied, there is little information concerning the long-term outcome of this disease. The aim of the present study was to follow up a patient population with GERD to identify variables that could be used to predict the disease course. From 1989 to 1991, we assessed 349 patients with GERD. Barium roentgenogram, esophagoscopy with biopsy, and ambulatory esophageal 24-hour pH monitoring were performed in each patient at baseline. One hundred eight outpatients with typical symptoms of gastroesophageal reflux and pathologic findings on 24-hour pH monitoring were included in the study. After diagnosis of GERD, patients were instructed to adhere to a specific diet and lifestyle regimen. Subsequently, on the basis of symptoms, the severity of esophagitis, and the degree of acid reflux, patients were assigned to a pharmacologic treatment using antacids, cisapride, ranitidine, and omeprazole, alone or in combination. Patients were followed up after 40 days and then yearly for 7 years using endoscopy and clinical examination. During the 7-year follow-up, 14 patients (13%) dropped out (2 of the 14 died of causes not related to GERD) and 6 patients (6%) underwent surgery to correct the reflux. Twenty-three patients (21%) discontinued pharmacologic treatment because of a stable improvement of their symptoms, whereas 65 (60%) continued the drug therapy. The present study demonstrated that reflux symptoms can improve and even disappear after treatment, but only in a small percentage of patients with GERD. The majority of patients must continue drug therapy. Moreover, a complete evaluation of patients at entry showed the following factors to be highly predictive of unfavorable disease progression: the presence and grade of esophagitis, a high grade of gastroesophageal reflux during 24-hour pH monitoring and while in the supine position, and the presence of hiatal hernia

Endoscopic Treatment of Anastomotic Biliary Stenosis in Patients With Orthotopic Liver Transplantation

The choledocho-choledochostomy stricture is one of the most frequent complications occurring after liver transplantation. Today endoscopic retrograde cholangiopancreatography may be considered one of the most common methodologic approaches for the diagnosis; at the same time it provides an effective treatment of the stenosis, avoiding more invasive surgery. Biliary flow through a strictured anastomosis definitely improves after endoscopic stenting which, in most cases, resolves the biliary obstruction syndrome; moreover, the stent could allow restoration of the anatomical and functional integrity of the common bile duct. We have successfully treated eight liver transplanted patients with biliary anastomotic stenosis by endoscopic stenting of the common bile duct or by balloon dilation (one patient). The stents were replaced every 3 to 4 months and then removed after 1 year of follow-up. We observed one patient with acute cholangitis due to the clogging of the prosthetic device.