Barbara Porowska

A Western single-center experience with endoscopic submucosal dissection for early gastrointestinal cancers

Endoscopic submucosal dissection (ESD) has gained worldwide acceptance as a treatment for early gastrointestinal cancers (EGICs). However, the management of these tumors in the Western world is still mainly surgical. Our aim was to evaluate the safety and feasibility of ESD at a European center. Based on the knowledge transferred by one of the most experienced Japanese institutions, we conducted a pilot study on 25 consecutive patients with EGICs located in the esophagus (n = 3), stomach (n = 7), duodenum (n = 1), and colon (n = 14) at our tertiary center over a 2-year-period. The main outcome measurements were complete (R0) resection, as well as en-bloc resection and the management of complications. The R0 and en-bloc resection rates were 100% and 84%, respectively. There were three cases of bleeding and five cases of perforation. With a median follow up of 18 months, two recurrences were observed. We conclude that ESD for early esophageal and gastric cancers is feasible and effective, while colonic ESD requires more expertise.

Anti-endomysial antibody of IgG1 isotype detection strongly increases the prevalence of coeliac disease in patients affected by type I diabetes mellitus

A strong association between type 1 insulin‐dependent diabetes mellitus (IDDM1) and coeliac disease (CD) is well documented, but it is known that prevalence values are underestimated. Serum anti‐endomysial antibodies (EMA), considered diagnostic for CD because of their high sensitivity and specificity, belong to the IgA class, but the existence of EMA of IgG1 isotype in the presence or absence of IgA deficiency was reported. In order to re‐evaluate the occurrence of CD in IDDM1 patients we performed a screening in IDDM1 patients using EMA of both isotypes. Ninety‐four adults affected by IDDM1 (unaffected by CD before enrolling) were enrolled and 83 blood donors as controls. All subjects were on a gluten‐containing diet. Histology and biopsy culture were performed. EMA IgA and IgG1 in sera and culture supernatants were detected. Serum EMA were positive in 13 of 94 IDDM1 patients (13·8%). Six of 13 presented IgA‐EMA, seven of 13 presented IgG1‐EMA. No EMA were found in the control population. Total intestinal atrophy was found in all six patients with serum IgA‐EMA and in five of seven with serum IgG1‐EMA. Diagnosis of CD was confirmed by histology and organ culture in all 13 patients with serum EMA. The prevalence of CD in the patients affected by IDDM1 was 6·4% for IgA‐EMA‐positive and 7·4% for IgG1‐EMA‐positive patients. We confirmed the prevalence of CD in the IDDM1 population obtained with IgA‐EMA screening only (6·4%). This prevalence value increases dramatically to 13·8% when IgG1‐EMA are also used in the screening. We conclude that IgG1‐EMA should also be sought whenever an IDDM1 patient undergoes screening for CD.

Microsurgical treatment of varicocele: selecting most appropriate shunt.

Microsurgical drainage of spermatic veins tailored to the hemodynamic type of varicocele was performed in 20 patients. In 14 cases the procedure was indicated as prophylaxis and in 6 cases as treatment of infertility. Complete regression of varicosities was observed in 75 percent as early as six days postoperatively, in 85 percent at two weeks, and in 90 percent at twelve months. In the remaining 10 percent, a consistent reduction of varicocele was found. No patient experienced progression of the disease. Eighty-three percent of the patients with altered seminal parameters showed an improvement of them at a mean follow-up of 9.1 months.

Antibiotic susceptibility, heteroresistance, and updated treatment strategies in Helicobacter pylori infection.

In this review, we discuss the problem of antibiotic resistance, heteroresistance, the utility of cultures and antibiotic susceptibility tests in Helicobacter pylori (Hp) eradication, as well as the updated treatment strategies for this infection. The prevalence of antibiotic resistance is increasing all over the world, especially for metronidazole and clarithromycin, because of their heavy use in some geographical areas. Heteroresistance (simultaneous presence of both susceptible and resistant strains in different sites of a single stomach) is another important issue, as an isolate could be mistakenly considered susceptible if a single biopsy is used for antimicrobial tests. We also examined literature data regarding eradication success rates of culture-guided and empiric therapies. The empiric therapy and the one based on susceptibility testing, in Hp eradication, may depend on several factors such as concomitant diseases, the number of previous antibiotic treatments, differences in bacterial virulence in individuals with positive or negative cultures, together with local antibiotic resistance patterns in real-world settings. Updated treatment strategies in Hp infection presented in the guidelines of the Toronto Consensus Group (2016) are reported. These suggest to prolong eradication therapy up to 14 days, replacing the old triple therapy with a quadruple therapy based on proton pump inhibitor (PPI), bismuth, metronidazole, and tetracycline for most of the patients, or as an alternative quadruple therapy without bismuth, based on the use of PPI, amoxicillin, metronidazole, and clarithromycin. The new drug vonoprazan, a first-in-class potassium-competitive acid blocker recently approved in Japan, is also considered to be a promising solution for Hp eradication, even for clarithromycin-resistant strains. Furthermore, there is growing interest in finding new therapeutic strategies, such as the development of vaccines or the use of natural resources, including probiotics, plants, or nutraceuticals.

Massive Fulminant Hemorrhage due to Splenic Vein Rupture in Pancreatitis

A fatal case of acute fulminant bleeding in pancreatitis associated with portal hypertension and caused by rupture of the splenic vein is reported, and the pathological and clinical features of this u

Letter: surveillance of Helicobacter pylori antibiotic resistance

SIRS, We read the article by McNulty et al. with great interest. The authors have issued very important data regarding Helicobacter pylori antibiotic resistance in patients attending for endoscopy in England and Wales. Culture and susceptibility testing based therapies seem to be the most logical step to overcome the problem of resistant strains, but, as described by the authors, culture can turn out to be negative, even in the presence of a positive urease test. Chronic PPI intake is considered to be the main cause of culture failure and when considering options for susceptibility testing, biopsy specimens should also be taken from the gastric body. In our experience, biopsy specimens for susceptibility testing should always include investigation of all three gastric regions especially in patients who had already received more than two therapeutic eradication schedules. We have investigated a group of patients affected with pangastritis and positive urea breath test, who had more than two previous eradication schedules. In these patients, we took three samples each from the antrum and corpus and another two from the fundus. This method should theoretically be very accurate, and hence, we expected the successful culture rate to be high. However, only 62% (31 out of 50) of our patients had a positive culture, and only one-third of them could be eradicated on the basis of susceptibility testing. In the positive culture group, we found very high resistance rates to all antibiotics (metronidazole 97%, levofloxacin 58%, clarithromycin 55%, amoxicillin 29% and tetracycline 23%). The policy to investigate all gastric regions is also important in revealing eventual presence of hetero-resistance. Partial data of our study have been published in abstract form. We fully concord with the authors when they state that clinicians should question their patients about the antibiotics used in their lifetime before selecting eradication therapies.

A simple ultrasonographic test for preoperative haemodynamic evaluation of varicocele

According to the haemodynamic classification of varicocele type I is caused by renospermatic reflux due to a proximal nutcracker phenomenon or to valvular insufficiency of the left internal spermatic vein. Type II is due to ileospermatic reflux and type III may be characterized by a combination of I and II refluxes. Although this classification proposed by Coolsaet is precious for decision making, it is seldom used in clinical practice being based on a complex angiographic evaluation which is invasive and exposes the patient (often a teenager or with infertility disturbances) to excessive radiations. The aim of the present study was to work up an original ultrasonographic test for preoperative haemodynamic evaluation of varicocele in order to indicate the most appropriate microsurgical treatment. Sixty-three patients underwent a preoperative clinico-echographic dynamic test which allowed to classify 76.9% of the cases as haemodynamic type I, 10.7% as type II and 12.3% as type III. Microsurgical shunts were performed in all cases and evaluation of recurrences was accurately carried out with ultrasonographic measurement of residual varicosities. In 6% of the cases varicosities were consistently reduced in size and in 94% absence of varicosities was demonstrated. Varicocele increased in size or was unchanged in none of the cases. In conclusion the test hereby described was shown to be simple and easily reproducible. It allowed a haemodynamic and objective classification of varicocele offering a unique opportunity for tailoring to the individual patient the most appropriate treatment. Furthermore, ultrasonographic postoperative follow-up is the most reliable and objective method to control the “true” incidence of post-varicocelectomy recurrences.

Long-term Results of Microsurgical Drainage for Idiopathic Varicocele

The long-term results of microsurgical shunts for idiopathic varicocele are reported in the present paper. Sixty-two patients with a total of 65 varicoceles (three were bilateral) were followed up for 1 to 8 years. Pre- and postoperative ultrasonographic evaluation of varicocele size was considered of great importance in order to reduce the bias of subjective clinical diagnosis and to achieve a reliable and objective follow-up. Microsurgical shunts were tailored to the type of reflux: renospermatic (76.9%), iliospermatic (10.8%) or mixed type (12.3%); 94% of patients experienced a complete morphologic disappearance of varicosities, while in 6% of the cases a consistent reduction of size was objectified although varicosities were still detectable at ultrasonographic examination. In patients with severe infertility a significant increase of seminal parameters was observed postoperatively and this improvement showed a higher statistical significance in patients aged <30 years.

Helicobacter pylori Infection and Gastric Dysbiosis: Can Probiotics Administration Be Useful to Treat This Condition?

Helicobacter pylori (Hp) is responsible for one of the most common infections in the world. The prevalence exceeds 50% of the population in developing countries, and approximately one-third of the adults are colonized in North Europe and North America. It is considered a major pathogenic agent of chronic gastritis, peptic ulcer, atrophic gastritis, gastric cancer, and mucosa-associated lymphoid tissue lymphoma (MALT). Hp colonization modifies the composition of gastric microbiota that could drive the development of gastric disorders. Currently, an emerging problem in Hp treatment is represented by the increasing rate of antimicrobial therapy resistance. In this context, the search for adjuvant agents can be very useful to overcome this issue and probiotics administration can represent a valid option. The aim of this review is to describe the gastric microbiota changes during Hp colonization, the mechanisms of action, and a possible role of probiotics in the treatment of this infection.

Pre–Endoscopy Screening of Helicobacter pylori Infection: Implication and Advantages

Over the last 30 years, upper gastrointestinal endoscopy has become the investigation of choice for patients with symptoms referable to upper gastrointestinal tract. Owing to the increasing number of patients who should be undergone endoscopy with a consequent high cost and a marked workload and medical expenses for the hospitals, it has been recommended that pre-endoscopy screening strategies might identify patients at low risk of having major pathology. These patients could avoid prompt endoscopy and might safely undergo different management.