Infection Control Practices and Outcomes of Endoscopy Units in the Lombardy Region of Italy: A Survey From the Italian Society of Digestive Endoscopy During COVID-19 Spread.

GOALS: The present survey from the Italian Society of Digestive Endoscopy (SIED-Società Italiana di Endoscopia Digestiva) was aimed at reporting infection control practice and outcomes at Digestive Endoscopy Units in a high-incidence area. BACKGROUND: Lombardy was the Italian region with the highest coronavirus disease-2019 (COVID-19) prevalence, at the end of March 2020 accounting for 20% of all worldwide deaths. Joint Gastro-Intestinal societies released recommendations for Endoscopy Units to reduce the risk of the contagion. However, there are few data from high-prevalence areas on adherence to these recommendations and on their efficacy. METHODS: A survey was designed by the Lombardy section of SIED to analyze (a) changes in activity and organization, (b) adherence to recommendations, (c) rate of health care professionals' (HCP) infection during the COVID-19 outbreak. RESULTS: In total, 35/61 invited centers (57.4%) participated; most modified activities were according to recommendations and had filtering face piece 2/filtering face piece 3 and water-repellent gowns available, but few had negative-pressure rooms or provided telephonic follow-up; 15% of HCPs called in sick and 6% had confirmed COVID-19. There was a trend (P=0.07) toward different confirmed COVID-19 rates among endoscopists (7.9%), nurses (6.6%), intermediate-care technicians (3.4%), and administrative personnel (2.2%). There was no correlation between the rate of sick HCPs and COVID-19 incidence in the provinces and personal protective equipment availability and use, whereas an inverse correlation with hospital volume was found. CONCLUSIONS: Adherence to recommendations was rather good, though a minority were able to follow all recommendations. Confirmed COVID-19 seemed higher among endoscopists and nurses, suggesting that activities in the endoscopy rooms are at considerable viral spread risk.

Paediatric gastric trichobezoar: the Rapunzel syndrome A report of two cases.

Rapunzel syndrome is a rare case of bowel obstruction resulting from hair ingestion (Trichobezoar). The obstruction can occur in any level of intestinal tract, but usually the stomach is primary involved. This syndrome is usually reported in patients affected by Trichotillomania or Pica syndrome, an obsessive-compulsive disorder that are characterized by an irresistible need to eat body hairs or non-digestible substances 1. When bowel obstruction occurs, it may be treated conservatively, but sometimes surgery is required. We reported two cases of Rapunzel Syndrome in two pediatric patients with different clinical presentation. Both patients were initially treated conservatively but eventually they underwent surgery. KEY WORDS: Bowel obstruction, Rapunzel syndrome, Trichobezoar.

Small-bowel capsule endoscopy with panoramic view: results of the first multicenter, observational study (with videos).

BACKGROUND AND AIMS: The first small-bowel video-capsule endoscopy (VCE) with 360° panoramic view has been developed recently. This new capsule has wire-free technology, 4 high-frame-rate cameras, and a long-lasting battery life. The aim of the present study was to assess the performance and safety profile of the 360° panoramic-view capsule in a large series of patients from a multicenter clinical practice setting. METHODS: Consecutive patients undergoing a 360° panoramic-view capsule procedure in 7 European Institutions between January 2011 and November 2015 were included. Both technical (ie, technical failures, completion rate) and clinical (ie, indication, findings, retention rate) data were collected by means of a structured questionnaire. VCE findings were classified according to the likelihood of explaining the reason for referral: P0, low; P1, intermediate; P2, high. RESULTS: Of the 172 patients (94 men; median age, 68 years; interquartile range, 53-75), 142 underwent VCE for obscure (32 overt, 110 occult) GI bleeding (OGIB), and 28 for suspected (17) or established (2) Crohn's disease (CD). Overall, 560 findings were detected; 252 were classified as P2. The overall diagnostic yield was 40.1%; 42.2% and 30.0% in patients with OGIB and CD, respectively. The rate of complete enteroscopy was 90.2%. All patients but one, who experienced capsule retention (1/172, 0.6%), excreted and retrieved the capsule. VCE failure occurred in 4 of 172 (2.3%) patients because of technical problems. CONCLUSIONS: This multicenter study, conducted in the clinical practice setting and based on a large consecutive series of patients, showed that the diagnostic yield and safety profile of the 360° panoramic-view capsule are similar to those of forward-view VCEs.

Bilirubin level fluctuation in drain discharge after hepatectomies justifies long-term drain maintenance.

BACKGROUND/AIMS: Need for abdominal drains after liver resection is debated. However, unrecognized bile leak is relatively frequent: to prevent bile collection we adopted the use of long-term drains. The aim of this study was to validate this policy checking the bilirubin concentration in the drain discharge and serum along the postoperative course. METHODOLOGY: A prospective cohort study enrolling 58 consecutive patients with liver tumors was carried out. All patients underwent liver resection and received abdominal drains which were maintained for at least 7 days postoperatively. The bilirubin concentration in serum and drain discharge was sampled on the 3rd, 5th and 7th postoperative days. RESULTS: No postoperative mortality and major morbidity were observed. The bilirubin level in drain discharge was higher on the 5th postoperative day than on the 3rd and 7th postoperative days: difference between the 3rd and 5th postoperative days was significant. No differences were observed among serum bilirubin levels on 3rd, 5th and 7th postoperative days. CONCLUSIONS: The bilirubin level in drain discharge increases late in the postoperative course. Therefore, bile leakage should be evaluated between the 5th and 7th postoperative days. The use of long-term drains helps protect against undiscovered collections and thus impacts postoperative course.

Techniques for hepatectomies without blood transfusion, focusing on interpretation of postoperative anemia.

HYPOTHESIS: Transient postoperative anemia is partially a physiologic phenomenon, and variations in blood transfusion rates after liver resection in different series in part are due to different interpretations of postoperative anemia. Based on the hypothesis that transient postoperative anemia is partially a physiologic phenomenon, we analyzed serum hemoglobin and hematocrit values in patients who underwent liver resection without blood transfusion to check fluctuations. DESIGN: Prospective cohort study. SETTING: Community hospital. PATIENTS: Forty-six consecutive patients with primary and metastatic liver tumors. INTERVENTIONS: Surgical treatment consisting of dissection technique performed under intermittent warm ischemia, using intraoperative ultrasonography, and without blood transfusion. MAIN OUTCOME MEASURES: Hematocrit and hemoglobin concentrations in serum sampled preoperatively and on the first, third, fifth, and seventh postoperative days. RESULTS: No postoperative mortality and major morbidity were observed. No patient received a blood transfusion. The hematocrit and hemoglobin concentrations in serum were significantly lower on the third postoperative day than on the first, fifth, and seventh postoperative days; differences among the first, fifth, and seventh postoperative days were not significant. CONCLUSIONS: The fluctuations of hemoglobin and hematocrit levels after liver resection showed a steady and significant decrease until the third postoperative day and then an increase. Therefore, a decrease in the hemoglobin and hematocrit levels between first and fifth postoperative days without evidence of active bleeding from drain discharge or any other possible source of bleeding does not justify blood administration.

Indication and contraindication for hepatic resection for liver tumors without fine-needle biopsy: validation and extension of an Eastern approach in a Western community hospital.

Fine-needle biopsy (FNB) is associated with problems, such as tumor seeding, which are not negligible. The aim of this study was to validate prospectively the accuracy of our diagnostic work-up without FNB, not just to address but also to rule out from a surgical program patients with focal liver lesions (FLLs). From September 2001 to July 2003, 89 patients were seen at an outpatient clinic for FLLs. Nine patients were excluded because of previous FNB and 18 were excluded because carrier of advanced disease. Sixty-two patients with 101 FLLs were included. Preoperative diagnoses were established by means of clinical histories, serum tumor marker levels, ultrasonography (US), and spiral computed tomography (CT). Other imaging modalities were carried out when it was considered necessary. Forty-eight patients underwent surgery, with histological confirmation of the preoperative diagnosis. The remaining 14 patients underwent a close follow-up. The preoperative diagnoses of 47 of the 48 patients who underwent surgery were confirmed (97.9%). All of the 14 patients ruled out for surgical treatment did not show FLL progression at 6-24 months of follow-up. Of the 9 patients who had FNB previously in other centers, 2 had a wrong histological diagnosis. In view of these results, a diagnostic work-up without FNB seems adequate either to include or to exclude patients with potentially resectable FLL from the surgical program and once more highlight the fact that the use of FNB should be drastically limited.

Contrast-enhanced intraoperative ultrasonography in surgery for hepatocellular carcinoma in cirrhosis.

Intraoperative ultrasonography (IOUS) is the most accurate diagnostic technique for staging hepatocellular carcinoma (HCC), but has low accuracy in differentiating the new nodules detected in the cirrhotic liver. The aim of this preliminary report is to evaluate whether contrast-enhanced intraoperative ultrasonography (CE-IOUS) could provide additional information to IOUS in patients with HCC. From August 2002 to July 2003, a prospective validation cohort study was conducted. For this purpose, 16 consecutive patients underwent liver resection for HCC using IOUS and CE-IOUS. Intraoperatively, in all patients 4.8 mL of SonoVue was injected intravenously through a peripheral vein. IOUS depicted 16 new focal liver lesions: 10 with no enhancement peculiar to HCC at CE-IOUS pattern and at histology (4) or imaging follow-up (6) proved to be benign; the remaining 6 had enhancement peculiar to HCC and histology confirmed this diagnosis. Two different patterns of enhancement were also recognized at CE-IOUS in those HCC nodules depicted preoperatively: one had no similarity to that observed at CT. CE-IOUS added findings to those of unenhanced IOUS in 50% of patients. These results show that IOUS accuracy and specificity is improved by CE-IOUS, with a great impact on surgical strategy and oncological radicality. Furthermore, a wider experience with vascular enhancement patterns with CE-IOUS could provide a new classification for HCC nodules.

Ultrasound-guided liver resections for hepatocellular carcinoma.

Imaging-guided interventional procedures have modified the approach to hepatocellular carcinoma including the surgical one. In fact, liver resections can be carried out with no mortality even if cirrhosis is associated, combining the needs for oncological radicality and liver parenchyma sparing mainly because of the extensive use of intraoperative ultrasonography either for tumor staging or resection-guidance. The aid of intraoperative ultrasonography is therefore optimizing the balance between the oncological radicality and the sparing of the highest amount of functioning liver parenchyma. Intraoperative ultrasonography allows the accomplishment of anatomical resections otherwise not possible such as the systematic segmentectomy. This is of crucial importance if taking into account that anatomical resections seem able to provide better prognosis than the non-anatomical one. However, if non-anatomical resection is carried out intraoperative ultrasonography guidance allows a better tumor clearance. Precise definition of hepatic vein anatomy and association with color Doppler enables hepatectomies otherwise not possible, expanding the indication at surgical resection. In conclusion, we can affirm that liver resection is an imaging-guided procedure and as every interventional imaging-guided procedure, its features are the highest therapeutic efficacy combined with the minimal invasiveness. Then, with the intraoperative ultrasonography guidance liver resection remains the treatment of choice of hepatocellular carcinoma.