V. Cesario

Small intestinal bacterial overgrowth recurrence after antibiotic therapy

OBJECTIVES:Current treatment for small intestinal bacterial overgrowth (SIBO) is based on courses of broad-spectrum antibiotics. No data concerning SIBO recurrence are available. The aims of the present study were to investigate SIBO recurrence as assessed by glucose breath test (GBT) after antibiotic treatment and conditions associated to SIBO recurrence.METHODS:Eighty consecutive patients affected by SIBO and decontaminated by rifaximin (1,200 mg per day for 1 wk) were enrolled. Diagnosis of SIBO was based on GBT. GBT was reassessed at 3, 6, and 9 months after evidence of GBT normalization. GBT positivity recurrence, predisposing conditions, and gastrointestinal symptoms were evaluated.RESULTS:Ten (10/80, 12.6%), 22 (22/80, 27.5%), and 35 (35/80, 43.7%) patients showed positivity to GBT at 3, 6, and 9 months after successful antibiotic treatment, respectively. At multivariate analysis, older age (OR 1.09, 95% CI 1.02–1.16), history of appendectomy (OR 5.9, 95% CI 1.45–24.19), and chronic use of proton pump inhibitors (PPIs) (OR 3.52, 95% CI 1.07–11.64) were significantly associated to GBT positivity recurrence. All gastrointestinal symptoms significantly increased at 3, 6, and 9 months in patients with evidence of GBT positivity recurrence.CONCLUSIONS:GBT positivity recurrence rate was high after antibiotic treatment. Older age, history of appendectomy, and chronic use of PPIs were associated with GBT positivity recurrence. Patients with evidence of GBT positivity recurrence showed gastrointestinal symptoms relapse thus suggesting SIBO recurrence.

Role of Gut Microbiota in Food Tolerance and Allergies

Alterations of commensal flora may cause various gastrointestinal and extraintestinal diseases, including food intolerances and food allergies. According to the ‘microflora hypothesis’, alterations in the composition of gut microbiota in industrialized countries have disturbed the mechanisms of mucosal immune tolerance. Over the past few years several studies have looked for a role for probiotics in the treatment of food allergies with promising results.

Radiofrequency ablation plus drug-eluting beads transcatheter arterial chemoembolization for the treatment of single large hepatocellular carcinoma

BACKGROUND Our aim was to evaluate the effectiveness of the single-step combined therapy with radiofrequency ablation and drug-eluting beads transarterial chemoembolization in single hepatocellular carcinoma (HCC) larger than 3cm. Secondary aim was to compare the results with those obtained in a matched population treated with drug-eluting beads transarterial chemoembolization alone. METHODS 40 consecutive cirrhotic patients with single HCC were prospectively enrolled and treated. Twenty-three patients had tumours between 3 and 5cm (Group A), and 17 larger than 5cm (Group B). Twenty cirrhotic patients with single HCC treated only with chemoembolization formed the control group. RESULTS Complete response at 1 month was achieved in 32/40 tumours (80%). During follow-up, complete response was maintained in 25 patients (25/40, 62.5%), and this rate was higher in Group A (69.6% vs 53%, p=0.008). The group treated with combined therapy showed a significantly lower 2-year recurrence (48.1% vs 78.2%, p<0.001) and significantly higher survival (91.1% vs 60.6%, p=0.004) than the group treated with chemoembolization alone. CONCLUSIONS Balloon-occluded-radiofrequency ablation plus drug-eluting beads transarterial chemoembolization is an effective treatment of HCC larger than 3cm not amenable to surgical resection, providing better results than transarterial chemoembolization alone. The best results are achieved in tumours up to 5cm.

Single-step multimodal locoregional treatment for unresectable hepatocellular carcinoma: balloon-occluded percutaneous radiofrequency thermal ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE)

PurposeThis study was undertaken to evaluate the feasibility, safety and efficacy of a new combined single-step therapy in patients with unresectable multinodular unilobar hepatocellular carcinoma (HCC), with at least one lesion >3 cm, with balloon-occluded radiofrequency ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE) of the main lesion and TACE of the other lesions. The second purpose of our study was to compare the initial effects in terms of tumour necrosis of this new combined therapy with those obtained in a matched population treated with TACE alone in a singlestep treatment in our centre in the previous year.Methods and materialsThis pilot study was approved by the institutional review board, and informed consent was obtained from all patients. Ten consecutive patients with multinodular (two to six nodules) unilobar unresectable HCC and with a main target lesion >3 cm (range, 3.5–6 cm) not suitable for curative therapy were enrolled in our single-centre multidisciplinary pilot study. The schedule consisted of percutaneous RFA (single 3-cm monopolar needle insertion) of the target lesion during occlusion of the hepatic artery supplying the tumour, followed by selective TACE, plus lobar TACE for other lesions (450-mg carboplatin and lipiodol plus temporary embolisation with SPONGOSTAN). Adverse events and intra- and periprocedural complications were clinically assessed. Early local efficacy was evaluated on 1-month follow-up multiphasic computed tomography (CT) on the basis of the Modified Response Evaluation Criteria in Solid Tumors (m-RECIST). A separate evaluation of target lesions in terms of enhancement, necrotic diameter and presence and distribution of lipiodol uptake was also performed.ResultsNo major complications occurred. Overall technical success, defined as complete devascularisation of all nodules during the arterial phase, was achieved in seven of 10 patients, with three cases of partial response (persistence of small hypervascular nodules). When considering only target lesions, technical success was obtained in all patients, with a nonenhancing area corresponding in shape to the previously identified HCC (necrotic diameter, 3.5–5 cm) and with circumferential peripheral lipiodol uptake (safety margin) of at least 0.5 cm (0.5–1.3cm).ConclusionsTACE and BO-RFA, plus TACE in a singlestep approach seems to be a safe and effective combined therapy for treating advanced, unresectable HCC lesions, allowing a high rate of complete local response to be achieved in large lesions also.RiassuntoObiettivoValutare nei pazienti affetti da epatocarcinoma multinodulare unilobare non resecabile, con almeno una lesione con diametro >3 cm, la fattibilità, la sicurezza e l’efficacia di una nuova terapia combinata con RFA durante occlusione arteriosa con catetere per PTA (BO-RFA) seguita da TACE della lesione principale e TACE delle restanti lesioni, in un’unica seduta. Endpoint secondario del nostro studio è stata la comparazione degli effetti iniziali in termini di necrosi tumorale delle lesioni trattate con questa nuova terapia combinata con quelli ottenuti in una popolazione di confronto trattata nel nostro centro nell’anno precedente con sola TACE.Materiali e metodiIl nostro studio pilota è stato approvato dal comitato etico e dall’autorità competente, e per tutti i pazienti è stato ottenuto un consenso informato scritto. Dieci pazienti consecutivi affetti da HCC multinodulare (2–6 noduli) unilobare, non resecabile e con una lesione target di diametro >3 cm di diametro (range 3,5–6 cm), non suscettibile di trattamenti di tipo curativo, sono stati arruolati nel nostro studio pilota monocentrico multidisciplinare. Il piano di trattamento è stato: RFA (ago con punta esposta da 3 cm) della lesione target durante occlusione endovascolare dell’arteria epatica afferente al tumore con catetere per PTA seguita da una TACE selettiva della stessa, più una TACE lobare per il trattamento delle altre lesioni (450 mg di carboplatino più lipiodol associato a embolizzazione temporanea con spongostan). Gli eventi avversi, cosÌ come le complicanze intra- e periprocedurali sono stati valutati clinicamente. L’efficacia locale in fase precoce è stata valutata mediante TC multifasica eseguita a un mese dalla procedura, sulla base dei criteri m-RECIST; separatamente è stata, inoltre, effettuata una valutazione delle lesioni target in termini di enhancement, diametro dell’area necrotica e presenza e distribuzione di lipiodol.RisultatiNon si sono verificate complicanze maggiori. Il successo tecnico complessivo, definito come la completa devascolarizzazione di tutti i noduli in fase arteriosa, è stato ottenuto in 7/10 pazienti con 3 risposte parziali (persistenza di piccoli noduli ipervascolarizzati). Considerando solo le lesioni target, il successo tecnico è stato raggiunto in tutti i pazienti, con la presenza di un’area priva di enhancement nella zona corrispondente al precedente nodulo di HCC (diametro necrotico 3,5–5 cm), con un accumulo periferico di lipiodol circonferenziale (margine di sicurezza), di almeno 0,5 cm (0,5–1,3 cm).ConclusioniIl trattamento combinato con BO-RFA seguita da TACE, in un approccio single-step, sembra essere una terapia sicura ed efficace per il trattamento dell’HCC avanzato non resecabile, permettendo di ottenere un alto tasso di risposta locale completa anche in lesioni di grandi dimensioni.

High Dose Amoxicillin-Based First Line Regimen is Equivalent to Sequential Therapy in the Eradication of H. pylori Infection

OBJECTIVE Helicobater (H.) pylori eradication rates with standard first-line triple therapy have declined to unacceptable levels. To date, amoxicillin-resistant H. pylori strains have rarely been detected. Whether increasing the dosage of amoxicillin in a standard 7 days eradicating regimen may enhance its efficacy is not known. The aim of this paper is to compare the efficacy of a 7 days high-dose amoxicillin based first-line regimen with sequential therapy. PATIENTS AND METHODS We have retrospectively analyzed data from 300 sex and age matched patients, who underwent 3 different therapeutic schemes: (1) standard LCA, lansoprazole 30 mg bid, clarithromycin 500 mg bid and amoxicillin 1000 mg bid for 7 days; (2) high dose LCA (HD-LCA), lansoprazole 30 mg bid, clarithromycin 500 mg bid and amoxicillin 1000 mg tid for 7 days; (3) sequential LACT, lansoprazole 30 mg bid plus amoxicillin 1000 mg bid for 5 days, followed by lansoprazole 30 mg bid, clarithromycin 500 mg bid and tinidazole 500 mg bid for 5 days. Eradication was confirmed by 13C-urea breath test. Compliance and occurrence of adverse effects were also assessed. RESULTS Eradication rates were: 55% for LCA, 75% for HD-LCA and 73% for LACT. Eradication rates were higher in HD-LCA group compared to LCA (p<0.01), while no significant differences were observed in HD-LCA group compared to LACT (p=ns). Compliance and occurrence of adverse effects were similar among groups. CONCLUSIONS High-dose amoxicillin based eradicating treatment is superior to standard triple therapy and equivalent to sequential therapy; compared to the latter, the shorter duration may represent an advantage.

Nodular lymphoid hyperplasia: A marker of low-grade inflammation in irritable bowel syndrome?

AIM To evaluate the prevalence of nodular lymphoid hyperplasia (NLH) in adult patients undergoing colonoscopy and its association with known diseases. METHODS We selected all cases showing NLH at colonoscopy in a three-year timeframe, and stratified them into symptomatic patients with irritable bowel syndrome (IBS)-type symptoms or suspected inflammatory bowel disease (IBD), and asymptomatic individuals undergoing endoscopy for colorectal cancer screening. Data collection included medical history and final diagnosis. As controls, we considered all colonoscopies performed for the aforementioned indications during the same period. RESULTS One thousand and one hundred fifty colonoscopies were selected. NLH was rare in asymptomatic individuals (only 3%), while it was significantly more prevalent in symptomatic cases (32%). Among organic conditions associated with NLH, the most frequent was IBD, followed by infections and diverticular disease. Interestingly, 31% of IBS patients presented diffuse colonic NLH. NLH cases shared some distinctive clinical features among IBS patients: they were younger, more often female, and had a higher frequency of abdominal pain, bloating, diarrhoea, unspecific inflammation, self-reported lactose intolerance and metal contact dermatitis. CONCLUSION About 1/3 of patients with IBS-type symptoms or suspected IBD presented diffuse colonic NLH, which could be a marker of low-grade inflammation in a conspicuous subset of IBS patients.

Percutaneous real-time sonoelastography as a non-invasive tool for the characterization of solid focal liver lesions: A prospective study

BACKGROUND Real-time sonoelastography is currently used for the characterization of superficial solid lesions such as thyroid and breast masses. This study evaluates the usefulness of percutaneous sonoelastography for the characterization of solid focal liver lesions. METHODS 30 out of 43 patients with 38 known liver lesions were included in a prospective, diagnostic study. Qualitative analysis (pattern of deformation, elasticity type of liver tumour) and semi-quantitative measurements (strain ratio, hardness percentage, histogram) were evaluated. Sensitivity, specificity, positive and negative predictive values were calculated and the area under the receiver operating characteristics curve was constructed. RESULTS Patterns A and C-D are specific of benign lesions and metastases respectively. The patterns for haemangiomas, focal nodular hyperplasia and metastases were significantly different to each other in terms of strain ratio, hardness percentage and histogram (p<0.05). A statistically significant difference (p<0.001) was observed between the median values of the 3 measured parameters for benign (1.02; 12%; 47) and malignant lesions (1.66; 65%; 20.5) respectively. The area under the receiver operating characteristics curve values for strain ratio, hardness percentage and histogram were 0.88, 0.89, and 0.86 respectively for cut-off values of 1.2, 45, and 30. CONCLUSIONS By percutaneous sonoelastography it is possible to differentiate benign versus malignant focal liver lesions, metastases in particular, with good diagnostic performance.

Su1468 Downstaging Therapy in Patients With Intermediate Stage HCC (BCLC B) as Bridge for Transplantation: The Hepatocatt Experience

Partially Hydrolyzed Guar Gum (PHGG) Attenuates Nonalcoholic Steatohepatitis (NASH) in Mice Through the Gut-Liver Axis Kazuhiro Katada, Yuji Naito, Tomohisa Takagi, Katsura Mizushima, Yasuki Higashimura, Tetsuya Okayama, Naohisa Yoshida, Kazuhiro Kamada, Kazuhiko Uchiyama, Ishikawa Takeshi, Osamu Handa, Hideyuki Konishi, Nobuaki Yagi, Hiroshi Ichikawa, Zenta Yasukawa, Makoto Tokunaga, Tsutomu Okubo, Lekh R. Juneja, Yoshito Itoh

Single-step multimodal locoregional treatment for unresectable hepatocellular carcinoma: balloon-occluded percutaneous radiofrequency thermal ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE)@@@Terapia loco-regionale multimodale dell’epatocarcinoma non resecabile con approccio single-step: termoablazione a radiofrequenza durante occlusione temporanea dell’arteria epatica con catetere da PTA (BO-RFA) plus chemioembolizzazione arteriosa transcatetere (TACE)

PurposeThis study was undertaken to evaluate the feasibility, safety and efficacy of a new combined single-step therapy in patients with unresectable multinodular unilobar hepatocellular carcinoma (HCC), with at least one lesion >3 cm, with balloon-occluded radiofrequency ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE) of the main lesion and TACE of the other lesions. The second purpose of our study was to compare the initial effects in terms of tumour necrosis of this new combined therapy with those obtained in a matched population treated with TACE alone in a singlestep treatment in our centre in the previous year.Methods and materialsThis pilot study was approved by the institutional review board, and informed consent was obtained from all patients. Ten consecutive patients with multinodular (two to six nodules) unilobar unresectable HCC and with a main target lesion >3 cm (range, 3.5–6 cm) not suitable for curative therapy were enrolled in our single-centre multidisciplinary pilot study. The schedule consisted of percutaneous RFA (single 3-cm monopolar needle insertion) of the target lesion during occlusion of the hepatic artery supplying the tumour, followed by selective TACE, plus lobar TACE for other lesions (450-mg carboplatin and lipiodol plus temporary embolisation with SPONGOSTAN). Adverse events and intra- and periprocedural complications were clinically assessed. Early local efficacy was evaluated on 1-month follow-up multiphasic computed tomography (CT) on the basis of the Modified Response Evaluation Criteria in Solid Tumors (m-RECIST). A separate evaluation of target lesions in terms of enhancement, necrotic diameter and presence and distribution of lipiodol uptake was also performed.ResultsNo major complications occurred. Overall technical success, defined as complete devascularisation of all nodules during the arterial phase, was achieved in seven of 10 patients, with three cases of partial response (persistence of small hypervascular nodules). When considering only target lesions, technical success was obtained in all patients, with a nonenhancing area corresponding in shape to the previously identified HCC (necrotic diameter, 3.5–5 cm) and with circumferential peripheral lipiodol uptake (safety margin) of at least 0.5 cm (0.5–1.3cm).ConclusionsTACE and BO-RFA, plus TACE in a singlestep approach seems to be a safe and effective combined therapy for treating advanced, unresectable HCC lesions, allowing a high rate of complete local response to be achieved in large lesions also.RiassuntoObiettivoValutare nei pazienti affetti da epatocarcinoma multinodulare unilobare non resecabile, con almeno una lesione con diametro >3 cm, la fattibilità, la sicurezza e l’efficacia di una nuova terapia combinata con RFA durante occlusione arteriosa con catetere per PTA (BO-RFA) seguita da TACE della lesione principale e TACE delle restanti lesioni, in un’unica seduta. Endpoint secondario del nostro studio è stata la comparazione degli effetti iniziali in termini di necrosi tumorale delle lesioni trattate con questa nuova terapia combinata con quelli ottenuti in una popolazione di confronto trattata nel nostro centro nell’anno precedente con sola TACE.Materiali e metodiIl nostro studio pilota è stato approvato dal comitato etico e dall’autorità competente, e per tutti i pazienti è stato ottenuto un consenso informato scritto. Dieci pazienti consecutivi affetti da HCC multinodulare (2–6 noduli) unilobare, non resecabile e con una lesione target di diametro >3 cm di diametro (range 3,5–6 cm), non suscettibile di trattamenti di tipo curativo, sono stati arruolati nel nostro studio pilota monocentrico multidisciplinare. Il piano di trattamento è stato: RFA (ago con punta esposta da 3 cm) della lesione target durante occlusione endovascolare dell’arteria epatica afferente al tumore con catetere per PTA seguita da una TACE selettiva della stessa, più una TACE lobare per il trattamento delle altre lesioni (450 mg di carboplatino più lipiodol associato a embolizzazione temporanea con spongostan). Gli eventi avversi, cosÌ come le complicanze intra- e periprocedurali sono stati valutati clinicamente. L’efficacia locale in fase precoce è stata valutata mediante TC multifasica eseguita a un mese dalla procedura, sulla base dei criteri m-RECIST; separatamente è stata, inoltre, effettuata una valutazione delle lesioni target in termini di enhancement, diametro dell’area necrotica e presenza e distribuzione di lipiodol.RisultatiNon si sono verificate complicanze maggiori. Il successo tecnico complessivo, definito come la completa devascolarizzazione di tutti i noduli in fase arteriosa, è stato ottenuto in 7/10 pazienti con 3 risposte parziali (persistenza di piccoli noduli ipervascolarizzati). Considerando solo le lesioni target, il successo tecnico è stato raggiunto in tutti i pazienti, con la presenza di un’area priva di enhancement nella zona corrispondente al precedente nodulo di HCC (diametro necrotico 3,5–5 cm), con un accumulo periferico di lipiodol circonferenziale (margine di sicurezza), di almeno 0,5 cm (0,5–1,3 cm).ConclusioniIl trattamento combinato con BO-RFA seguita da TACE, in un approccio single-step, sembra essere una terapia sicura ed efficace per il trattamento dell’HCC avanzato non resecabile, permettendo di ottenere un alto tasso di risposta locale completa anche in lesioni di grandi dimensioni.

Terapia loco-regionale multimodale dell'epatocarcinoma non resecabile con approccio single-step: termoablazione a radiofrequenza durante occlusione temporanea dell'arteria epatica con catetere da PTA (BO-RFA) plus chemioembolizzazione arteriosa transcatetere (TACE)

PurposeThis study was undertaken to evaluate the feasibility, safety and efficacy of a new combined single-step therapy in patients with unresectable multinodular unilobar hepatocellular carcinoma (HCC), with at least one lesion >3 cm, with balloon-occluded radiofrequency ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE) of the main lesion and TACE of the other lesions. The second purpose of our study was to compare the initial effects in terms of tumour necrosis of this new combined therapy with those obtained in a matched population treated with TACE alone in a singlestep treatment in our centre in the previous year.Methods and materialsThis pilot study was approved by the institutional review board, and informed consent was obtained from all patients. Ten consecutive patients with multinodular (two to six nodules) unilobar unresectable HCC and with a main target lesion >3 cm (range, 3.5–6 cm) not suitable for curative therapy were enrolled in our single-centre multidisciplinary pilot study. The schedule consisted of percutaneous RFA (single 3-cm monopolar needle insertion) of the target lesion during occlusion of the hepatic artery supplying the tumour, followed by selective TACE, plus lobar TACE for other lesions (450-mg carboplatin and lipiodol plus temporary embolisation with SPONGOSTAN). Adverse events and intra- and periprocedural complications were clinically assessed. Early local efficacy was evaluated on 1-month follow-up multiphasic computed tomography (CT) on the basis of the Modified Response Evaluation Criteria in Solid Tumors (m-RECIST). A separate evaluation of target lesions in terms of enhancement, necrotic diameter and presence and distribution of lipiodol uptake was also performed.ResultsNo major complications occurred. Overall technical success, defined as complete devascularisation of all nodules during the arterial phase, was achieved in seven of 10 patients, with three cases of partial response (persistence of small hypervascular nodules). When considering only target lesions, technical success was obtained in all patients, with a nonenhancing area corresponding in shape to the previously identified HCC (necrotic diameter, 3.5–5 cm) and with circumferential peripheral lipiodol uptake (safety margin) of at least 0.5 cm (0.5–1.3cm).ConclusionsTACE and BO-RFA, plus TACE in a singlestep approach seems to be a safe and effective combined therapy for treating advanced, unresectable HCC lesions, allowing a high rate of complete local response to be achieved in large lesions also.RiassuntoObiettivoValutare nei pazienti affetti da epatocarcinoma multinodulare unilobare non resecabile, con almeno una lesione con diametro >3 cm, la fattibilità, la sicurezza e l’efficacia di una nuova terapia combinata con RFA durante occlusione arteriosa con catetere per PTA (BO-RFA) seguita da TACE della lesione principale e TACE delle restanti lesioni, in un’unica seduta. Endpoint secondario del nostro studio è stata la comparazione degli effetti iniziali in termini di necrosi tumorale delle lesioni trattate con questa nuova terapia combinata con quelli ottenuti in una popolazione di confronto trattata nel nostro centro nell’anno precedente con sola TACE.Materiali e metodiIl nostro studio pilota è stato approvato dal comitato etico e dall’autorità competente, e per tutti i pazienti è stato ottenuto un consenso informato scritto. Dieci pazienti consecutivi affetti da HCC multinodulare (2–6 noduli) unilobare, non resecabile e con una lesione target di diametro >3 cm di diametro (range 3,5–6 cm), non suscettibile di trattamenti di tipo curativo, sono stati arruolati nel nostro studio pilota monocentrico multidisciplinare. Il piano di trattamento è stato: RFA (ago con punta esposta da 3 cm) della lesione target durante occlusione endovascolare dell’arteria epatica afferente al tumore con catetere per PTA seguita da una TACE selettiva della stessa, più una TACE lobare per il trattamento delle altre lesioni (450 mg di carboplatino più lipiodol associato a embolizzazione temporanea con spongostan). Gli eventi avversi, cosÌ come le complicanze intra- e periprocedurali sono stati valutati clinicamente. L’efficacia locale in fase precoce è stata valutata mediante TC multifasica eseguita a un mese dalla procedura, sulla base dei criteri m-RECIST; separatamente è stata, inoltre, effettuata una valutazione delle lesioni target in termini di enhancement, diametro dell’area necrotica e presenza e distribuzione di lipiodol.RisultatiNon si sono verificate complicanze maggiori. Il successo tecnico complessivo, definito come la completa devascolarizzazione di tutti i noduli in fase arteriosa, è stato ottenuto in 7/10 pazienti con 3 risposte parziali (persistenza di piccoli noduli ipervascolarizzati). Considerando solo le lesioni target, il successo tecnico è stato raggiunto in tutti i pazienti, con la presenza di un’area priva di enhancement nella zona corrispondente al precedente nodulo di HCC (diametro necrotico 3,5–5 cm), con un accumulo periferico di lipiodol circonferenziale (margine di sicurezza), di almeno 0,5 cm (0,5–1,3 cm).ConclusioniIl trattamento combinato con BO-RFA seguita da TACE, in un approccio single-step, sembra essere una terapia sicura ed efficace per il trattamento dell’HCC avanzato non resecabile, permettendo di ottenere un alto tasso di risposta locale completa anche in lesioni di grandi dimensioni.