Vincenzo Giorgio Mirante

Percutaneous ablation procedures in cirrhotic patients with hepatocellular carcinoma submitted to liver transplantation: Assessment of efficacy at explant analysis and of safety for tumor recurrence

Aims of this retrospective study were to analyze the efficacy and safety of percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA) in cirrhotic patients with hepatocellular carcinoma (HCC) submitted to orthotopic liver transplantation (OLT). We studied 40 patients undergoing OLT in whom 46 HCC nodules had been treated with PEI (13 nodules), RFA (30 nodules), or PEI+RFA (3 nodules). Child‐Turcotte‐Pugh class was A in 18 cases, B in 18, and C in 4. The mean waiting time for OLT was 9.5 months. The effectiveness of ablation techniques was evaluated by histological examination of the explanted livers. Complete necrosis was found in 19 nodules (41.3%), partial or absent necrosis in 27 nodules (58.7%). Among the 30 nodules treated by RFA, 14 were completely necrotic (46.7%) and 16 demonstrated partial necrosis (53.3%). Considering the 13 neoplasms undergoing PEI, 3 nodules showed complete necrosis (23.1%), 6 partial necrosis (46.1%), and 4 absent necrosis (30.8%). The rate of complete necrosis was 53.1% for nodules smaller than 3 cm and 14.3% for larger lesions (P = 0.033) but increased to 61.9% when considering only the lesions smaller than 3 cm treated by RFA. During the follow up, HCC recurred in 3 patients treated by PEI. No cases of HCC recurrence at the abdominal wall level were recorded. Percutaneous ablation procedures are effective treatments in cirrhotic patients with HCC submitted to OLT and are not associated to an increased risk of tumor recurrence. RFA provides complete necrosis in most nodules smaller than 3 cm, and appears to be the best treatment option in these cases. (Liver Transpl 2005;11:1117–1126.)

Liver transplantation for Wilson's disease: The burden of neurological and psychiatric disorders

A retrospective data analysis on liver transplantation for Wilsons disease (WD) was performed among Italian Liver Transplant Centers. Thirty‐seven cases were identified. The main indication for liver transplantation was chronic advanced liver disease in 78% of patients. Mixed hepatic and neuropsychiatric symptoms were recorded in 32.3%. Eight patients presented with fulminant liver failure; 44.8% were on medical treatment. Patient and graft survival at 3 months, 12 months, 3 years, 5 years, and 10 years after transplantation were, respectively, 91.8%, 89.1%, 82.9%, 75.6%, and 58.8%, and 85.3%, 83.0%, 77.1%, 70.3%, and 47.2%. Neurological symptoms significantly improved after orthotopic liver transplantation (OLT), but the survival of patients with mixed hepatic and neuropsychiatric involvement was significantly lower than in patients with liver disease alone (P = 0.04). WD characterized by hepatic involvement alone is a rare but good indication for liver transplantation when specific medical therapy fails. Patients with neuropsychiatric signs have a significantly shorter survival even though liver transplantation has a positive impact on neurological symptoms. In conclusion, a combination of hepatic and neuropsychiatric conditions deserves careful neurological evaluation, which should contraindicate OLT in case of severe neurological impairment. (Liver Transpl 2005;11:1056–1063.)

Esophageal chemical clearance is impaired in gastro-esophageal reflux disease--a 24-h impedance-pH monitoring assessment.

Impedance‐pH monitoring allows assessment of retrograde and antegrade intra‐esophageal movement of fluids and gas. Reflux is followed by volume clearance and chemical clearance, elicited by secondary and swallow‐induced peristalsis, respectively. We aimed to assess whether chemical clearance is impaired in gastro‐esophageal reflux disease (GERD).

The added value of quantitative analysis of on‐therapy impedance‐pH parameters in distinguishing refractory non‐erosive reflux disease from functional heartburn

Background  By analysis of symptom‐reflux association, endoscopy‐negative refractory heartburn can be related to acid/non‐acid refluxes with impedance‐pH monitoring. Unfortunately, patients frequently do not report symptoms during the test. We aimed to assess the contribution of quantitative analysis of impedance‐pH parameters added to symptom‐reflux association in evaluating patients with endoscopy‐negative heartburn refractory to high‐dose proton pump inhibitor therapy.

The added diagnostic value of postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on-therapy impedance-pH monitoring

On‐therapy impedance‐pH monitoring in proton pump inhibitor (PPI)‐refractory gastroesophageal reflux disease (GERD) yielded conflicting results. We aimed to assess the diagnostic value of postreflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) in PPI‐refractory heartburn.

Cholangiocarcinoma and malignant bile duct obstruction: A review of last decades advances in therapeutic endoscopy

In the last decades many advances have been achieved in endoscopy, in the diagnosis and therapy of cholangiocarcinoma, however blood test, magnetic resonance imaging, computed tomography scan may fail to detect neoplastic disease at early stage, thus the diagnosis of cholangiocarcinoma is achieved usually at unresectable stage. In the last decades the role of endoscopy has moved from a diagnostic role to an invaluable therapeutic tool for patients affected by malignant bile duct obstruction. One of the major issues for cholangiocarcinoma is bile ducts occlusion, leading to jaundice, cholangitis and hepatic failure. Currently, endoscopy has a key role in the work up of cholangiocarcinoma, both in patients amenable to surgical intervention as well as in those unfit for surgery or not amenable to immediate surgical curative resection owing to locally advanced or advanced disease, with palliative intention. Endoscopy allows successful biliary drainage and stenting in more than 90% of patients with malignant bile duct obstruction, and allows rapid reduction of jaundice decreasing the risk of biliary sepsis. When biliary drainage and stenting cannot be achieved with endoscopy alone, endoscopic ultrasound-guided biliary drainage represents an effective alternative method affording successful biliary drainage in more than 80% of cases. The purpose of this review is to focus on the currently available endoscopic management options in patients with cholangiocarcinoma.

Colonic Postpolypectomy Bleeding Is Related to Polyp Size and Heparin Use

Background/Aims We studied factors influencing colon postpolypectomy bleeding (PPB), with a focus on antithrombotic and anticoagulation therapy. Methods We conducted a retrospective case-control study of all patients who underwent polypectomy at our tertiary referral center in Italy between 2007 and 2014. Polyp characteristics (number of polyps removed per patient, size, morphology, location, resection technique, prophylactic hemostasis methods) and patient characteristics (age, sex, comorbidities, medication) were analyzed. Results The case and control groups included 118 and 539 patients, respectively. The two groups differed in the frequency of comorbidities (69% vs. 40%, p=0.001), polyps removed (27% vs. 18%, p=0.02), and use of heparin therapy (23% vs. 1%, p<0.001). A total of 279 polyps in the case group and 966 in the control group were nonpedunculated (69% vs. 81%, p=0.01) and measured ≥10 mm (78% vs. 32%, p=0.001). Multivariate analysis showed that polyps ≥10 mm (odds ratio [OR], 6.1; 95% confidence interval [CI], 2.3–15.5), administration of heparin (OR, 16.5; 95% CI, 6.2–44), comorbidity (OR, 2.3; 95% CI, 1.4–3.9), and presence of ≥2 risk factors (OR, 3.2; 95% CI, 1.7–6.0) were associated with PPB. Conclusions The incidence of PPB increases with polyp size ≥10 mm, heparin use, comorbidity, and presence of ≥2 risk factors.

Over-the-scope clip closure for treatment of post-pancreaticogastrostomy pancreatic fistula: A case series.

The over‐the‐scope clip (OTSC) system is a recently developed endoscopic device. In the last few years, it has been successfully used for severe bleeding or deep wall lesions, or perforations of the gastrointestinal (GI) tract. We hereby report a series of patients with post‐pancreaticogastrostomy pancreatic fistula in whom OTSC were used as endoscopic treatment.

Retroperitoneal Schwannoma: When EUS-Guided FNA can Avoid Surgery

Schwannomas are rare benign tumor that arises from peripheral or cranial nerve. Commonly, they occur into the head or neck and rarely into the retroperitoneum or pancreas. Usually they are asymptomatic tumor, discovered incidentally. Final diagnosis is generally confirmed after surgical intervention. The possibility to reach the lesion by EUS and to perform FNA can avoid invasive procedures. Here we discuss a rare case of retroperitoneal schwannoma diagnosed by Endoscopic ultrasound (EUS) guided Fine needle aspiration (FNA).

Feasibility and efficacy of double over-the-scope clipping for colonic iatrogenic perforation

Colorectal iatrogenic perforation is a rare adverse event in diagnostic colonoscopy, occurring in a range of 0.03% to 0.8% of cases. Risk factors include endoscopist’s inexperience, female gender, pericolic adhesions, inflammatory colonic diseases, severe diverticular disease, and weakened colonic-wall tissues because of older age. The over-the-scope clip (OTSC, Ovesco Endoscopy GmbH, Tübingen, Germany) is a useful tool, recommended as first-line endoscopic treatment for endoscopic acute iatrogenic perforation, which can help to avoid emergency surgical repair. However, the deployment of an OTSC to completely close the defect may be challenging in some cases because of the size, the position of the hole (ie, sigmoid-rectal junction), and the presence of other endoscopic devices (ie, through-thescope clip or OTSC). To the best of our knowledge, the deployment of 2 adjacent OTSCs has not been described in the medical literature. Here we report the case of an 89-year-old woman referred to our unit for colonoscopy (CFHQ190L; Olympus Co, Tokyo, Japan) because of a positive hemoccult test result and anemia. Because of pericolic adhesions in a