Accuracy of narrow-band imaging in predicting the histology of anal intraepithelial lesions.

BACKGROUND AND AIM: Anal intraepithelial neoplasia (AIN) is the precursor of anal squamous carcinoma, frequently underappreciated by most gastroenterologists. Purpose of the study is to assess the diagnostic accuracy of narrow-band imaging (NBI) in predicting the histology of anal lesions, considering a new NBI classification. METHODS: This is a retrospective analysis of consecutive patients with suspected anal squamous intraepithelial lesions (SILs) and superficially invasive squamous cell carcinoma (SISCCA) who underwent anorectal-sigmoidoscopy. Three expert endoscopists reviewed all the images collected during colonoscopies in white light and NBI in order to generate a practical classification of three main different NBI patterns. RESULTS: After the modified Delphi process, the final NBI classification, mainly based on intrapapillary capillary loops (IPCL) changes included three different NBI pattern. NBI pattern I: elongation of IPCL toward epithelial surface; NBI pattern 2: thickened and tortuous IPCL; NBI pattern 3: mosaic-like disposition of IPCL. We found that NBI pattern positively correlated to the histologic type of the lesions and tumor grade (Spearman's rho = 0.9671, P = 0.0000). Among 58 anal lesions included, 41/41 (100%) LSILs have been classified as NBI pattern I, 10/11 (90.91%) HSILs as NBI pattern II, 1/11 HSIL as NBI pattern I, 4/4 SISCCA as NBI pattern III and 2/2 invasive cancer as NBI pattern III. Diagnostic accuracy of NBI pattern II or III in predicting histology differentiating HSIL or SISCCA/IC versus LSIL showed a sensitivity of 100%, (95% CI: 92.3-100%) and a specificity of 94.1% (95% CI: 83.8-98.3%). CONCLUSION: The accuracy of this new NBI score system in predicting the histology of anal lesions showed encouraging data in term of sensitivity and specificity in differentiating HSIL or SISCCA/IC versus LSIL, but the clinical usefulness and application of these findings should be evaluated in a prospective larger study.

Effects of Robuvit® on the progression of non-alcoholic fatty liver disease.

BACKGROUND: The aim of this study was to evaluate the effects of Robuvit® in preventing the progression of chronic hepatitis (CH) in non-alcoholic fatty liver disease (NAFLD) which encompasses the entire spectrum of fatty liver disease, from isolated steatosis to non-alcoholic steatohepatitis (NASH). METHODS: One group of patients followed the Standard management (SM) and were assigned as controls while the supplementation group followed the SM and additionally took 2 Robuvit® capsules daily for 3 months (200 mg/day). RESULTS: 34 subjects with NAFLD were included in the study. The two groups completing 90 days were comparable at baseline with 18 being supplemented with Robuvit® and 16 in the control group. The tolerability was very good, and no side effects were observed with the supplement. Fasting glucose levels were significantly lower after 3 months with Robuvit® (P<0.05) compared to controls. The increased serum aspartate aminotransferase levels (AST), considered the key metabolic value in these patients, decreased significantly with Robuvit® (P<0.05) compared to controls. Serum alanine aminotransferase levels (ALT) also decreased significantly with the supplement compared to controls (P<0.05). Platelet count and albumin levels improved significantly with Robuvit® (P<0.05) in comparison to standard management. No other significant changes were observed. The APRI score (the AST/platelet ratio index) was also decreased with the supplementation compared to controls (P<0.05). A high APRI score provides an estimate of the possibility of the liver to develop fibrosis and eventually cirrhosis. After Robuvit® supplementation, the ultrasound characterization showed a significant decrease in the size of the liver in association with a lower echogenicity, which represents less fibrotic changes due to collagen accumulation. CONCLUSIONS: Robuvit® improved liver function in NAFLD and prevented progression to liver fibrosis by improving hepatic metabolism in a relatively short period of time. Numerous people are affected by NAFLD, many of them with subclinical symptoms. But to date, there are no specific, definite treatment options. Prolonged evaluations of Robuvit® in a larger group of subjects is suggested.

Redesign of a GI endoscopy unit during the COVID-19 emergency: A practical model.

The pandemic diffusion of the SARS-CoV-2 infection throughout the world required measures to prevent and strategies to control the infection, as well as the reallocation of the hospital structures in order to take care of an increased number of infected patients. Endoscopy Units should be able to perform endoscopic procedures on COVID-19 infected as well as on noninfected patients. The aim of this manuscript is to propose a model for a fast reorganization of the endoscopy department environment in order to safely perform endoscopic procedures in this Pandemic COVID-19 scenario, according to the current advices given by the Scientific Societies.

Pycnogenol® supplementation improves the control of irritable bowel syndrome symptoms.

BACKGROUND: The aim of this registry was to evaluate the effects of Pycnogenol® on the main symptoms of irritable bowel syndrome (IBS) in otherwise healthy individuals. METHODS: This study included 77 healthy individuals with symptoms of IBS. The patients were divided into three groups: group 1 was treated with Buscopan (10 mg when needed), group 2 (Antispasmina col forte; 50 mg papaverine hydrochloride+10 mg belladonna extract when needed) and 3 (Pycnogenol® 150 mg/day) for 3 weeks. RESULTS: The number of painful attacks was comparable in all groups after four weeks. Mild pain on manual abdomen pressure was decreased in all groups, with the improvement in the Pycnogenol® group significantly more pronounced that in both control groups (P<0.05). Perceived abdominal bowel movements/distension were significantly relieved in group 2 (Antispasmina Col Forte) and 3 (Pycnogenol®) (P<0.05) in comparison with Buscopan (group 1). CONCLUSIONS: Pycnogenol® has shown a significant, protective and preventive activity on IBS symptoms, and thus it may represent a potential "soft" approach to IBS.

Endoscopic resection for superficial colorectal neoplasia in Italy: a prospective multicentre study.

BACKGROUND: Since there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients. METHODS: Prospective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥10mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months. RESULTS: Overall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. En bloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16-4.26]; p=0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56-4.87]; p=0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions<20mm, follow-up limited to 1 year. CONCLUSION: In this registry study the endoscopic resection of colorectal lesions was safe and achieved high rates of long-term endoscopic clearance.

Kidney flow and function in hypertension: protective effects of pycnogenol in hypertensive participants--a controlled study.

This study evaluated the effects of Pycnogenol as an adjunct to angiotensin-converting enzyme (ACE)-inhibitor ramipril treatment of hypertensive patients presenting with early signs of renal function problems. One group of 26 patients was medicated with 10 mg ramipril per day only; a second group of 29 patients took Pycnogenol in addition to the ACE inhibitor over a period of 6 months. At trial end, a lowered systolic and diastolic blood pressure was found in both groups, with a significant further reduction of diastolic pressure in the group given Pycnogenol in addition to ramipril. The major aim of this study was the investigation of kidney-protective effects of Pycnogenol. Urinary albumin decreased from 87 +/- 23 to 64 +/- 16 mg/d with ramipril only. Additional Pycnogenol lowered albumin significantly better from 91 +/- 25 to 39 +/- 13 mg/day (P < .05). In both groups, serum creatinine was lowered; however, only in the combination treatment group did the effect reached statistical significance. In both groups, CRP levels decreased from 2.1 to 1.8 with ramipril and from 2.2 to 1.1 with the ramipril-Pycnogenol combination; the latter reached statistical significance. Kidney cortical flow velocity was investigated by Doppler color duplex ultrasonography. Both systolic and diastolic flow velocities increased significantly after 6 months medication with ramipril. The addition of Pycnogenol to the regimen statistically significantly further enhanced kidney cortical flow velocities, by 8% for diastolic flow and 12% for systolic flow, relative to values found for the group taking ramipril only. The protective effects of Pycnogenol for initial kidney damage found in this study warrant further research with a larger number of patients and over a longer period of time.

The value of high-resolution three-dimensional endorectal ultrasonography in the management of submucosal invasive rectal tumors.

PURPOSE: The aims of this prospective study were 1) to evaluate the accuracy of high-resolution three-dimensional endorectal ultrasonography in distinguishing slight from massive submucosal invasion of early rectal tumors, and 2) to determine the technology's role in treatment selection. METHODS: A total of 142 consecutive patients with clinically possible pT1 rectal cancers underwent three-dimensional endorectal ultrasonography. Slight or massive irregularity of the hyperechoic submucosal layer was considered to characterize uT1-slight or uT1-massive tumors. Treatment was selected on the basis of ultrasonographic findings: endoscopic resection or full-thickness transanal local excision was selected for uT1-slight lesions, and radical resection was selected for uT1-massive tumors. Ultrasonographic staging was compared with histopathologic staging. RESULTS: One hundred twenty-six patients were included in the final analyses. Three-dimensional endorectal ultrasonography staged 77 lesions as uT0, 25 as uT1-slight, 20 as uT1-massive, and 4 as uT2. Histologically, adenomas were found in 75 patients and tumor invasion was found in 44 lesions (24 pT1-slight, 16 pT1-massive, 4 pT2). The overall kappa for the concordance between ultrasonographic and histopathologic stagings was 0.81 (95% confidence interval, 0.72-0.89). No invasive carcinomas remained undetected. The depth of invasion was correctly determined in 87.2% of both pT1-slight and pT1-massive lesions. Considering the complete series of 126 patients, the accuracy of this modality in selecting appropriate management was 95.2% (kappa, 0.84; 95% confidence interval, 0.71-0.96). Adequate surgery was performed in 87.5% of pT1 tumors. CONCLUSION: Three-dimensional endorectal ultrasonography is useful for assessing the depth of submucosal invasion in early rectal cancer and for selecting therapeutic options.

Fecal calprotectin levels in patients with colonic polyposis.

CONTEXT: The usefulness of stool calprotectin determination in diagnosis of inflammatory disease of the colon has been reported; information about its usefulness for patients with polyposis are scarce, however. OBJECTIVE: To evaluate the significance of stool calprotectin concentrations for patients affected by colonic polyposis. PATIENTS: Sixty-three consecutive patients (35 males, 28 females, mean age 60.3 years, range 39-78 years) were enrolled: 26 patients (41.3%) with polyps, 17 patients (27.0%) with asymptomatic diverticular disease, and 20 subjects (31.7%) with normal endoscopic appearance of the colon. RESULTS: Stool calprotectin concentrations were 17.4 +/- 24.5 microg g(-1) for patients with colonic polyposis, significantly higher than concentrations for patients with diverticulosis (7.1 +/- 5.7 microg g(-1); P = 0.026) or for patients with normal appearance of the colon (calprotectin 6.0 +/- 5.8 microg g(-1); P = 0.003). For patients with a single polyp, stool calprotectin concentrations were similar to those for patients with multiple polyps. Calprotectin fecal concentrations for patients with sessile polyps and those with flat polyps were not significantly different. Calprotectin concentrations were not significantly related to the size of the polyps. CONCLUSION: Our data show that colonic polyposis may cause an increase in stool calprotectin values and that these colonic lesions should be suspected when elevated stool calprotectin concentrations are found.

Clinical usefulness of gastric-juice analysis in 2007: the stone that the builders rejected has become the cornerstone.

BACKGROUND: Gastric juice is usually discarded during upper-GI endoscopy. OBJECTIVE: By using a novel device, the Mt 21-42, we evaluated the potential of this important organic fluid in clinical practice, exploring its contribution to the diagnosis of Helicobacter pylori infection and atrophic gastritis of the oxyntic mucosa (AGOM). DESIGN AND PATIENTS: A multicenter study (17,907 patients; 10 endoscopy units) estimated the frequency of diagnosis of AGOM and H pylori infection in routine endoscopic practice. A prospective study (216 patients) at 1 of these units aimed to determine the real prevalence of these conditions and the possible benefits of gastric juice analysis. We considered gastric juice pH and ammonium concentration, endoscopic and histologic features, serologic parameters for atrophy and H pylori, gastric acid secretion, and costs. RESULTS: We found that H pylori infection and, even more markedly, AGOM were greatly underdiagnosed in routine endoscopic practice (20.1% and 0.8% vs 49.1% and 12.5% in the prospective study, respectively), because of the intrinsic limitations of the conventional tests and lack/inappropriateness of biopsy planning. Gastric-juice analysis proved to be a cheap, simple, and effective way to prevent such underdiagnosis and allowed detection of atrophic gastritis and H pylori in 96% and 98% of cases, and saved costs (cost-effectiveness ratio 209 vs 274-5047). CONCLUSIONS: Gastric juice provided a valuable source of clinicopathologic information that, properly analyzed, allowed detection of the main risk factors for gastric cancer (H pylori and atrophic gastritis), overcoming the diagnostic limitations associated with these conditions and also producing time and cost savings.

Improvement of microcirculation and healing of venous hypertension and ulcers with Crystacide: evaluation with a microcirculatory model, including free radicals, laser doppler flux, and PO2/PCO2 measurements.

In 32 patients with chronic venous insufficiency and venous hypertension associated with ulcerations, the effects of the local application of a hydrogen peroxide cream (Crystacide) applied onto the skin was evaluated using a complex, proportional, microcirculatory model to assess and quantify venous microangiopathy after local treatment. A comparative group treated without Crystacide was included. Laser Doppler flowmetry was used to assess skin perfusion (flux and venoarteriolar response) in association with transcutaneous PO2 and PCO2 measurements. Local plasma free radicals were evaluated in the area surrounding the venous ulcer using the D-Roms test. Crystacide was applied around and on the ulcer for 10 days. Crystacide was more effective than the control treatments. PO2 was increased (improved, P < .05), and plasma free radicals, PCO2, and laser Doppler flowmetry were decreased (improving toward normal values, P < .05). Also, the ulcerated area was significantly smaller at 10 days in the Crystacide group in comparison with controls (P < .05). In the proportional microcirculatory model, all parameters indicated an important level of improvement significantly larger than in controls. In conclusion, in chronic venous insufficiency and venous ulcerations, local treatment with Crystacide (10 days) improves the microcirculation and decreases skin free radicals, thus improving healing.

Microcirculatory effects of Viatromb spray gel heparin in chronic venous insufficiency: evaluation of TcPO2 and PCO2--a product evaluation study.

The evolution of microcirculatory methods and the definition of the concept of venous microangiopathy allow the study in a quantitative way of microcirculatory changes produced by pharmacologic treatments at the areas most frequently and severely affected by chronic venous insufficiency (CVI), venous hypertensive microangiopathy, and venous ulcerations. This pilot study compares subjects with CVI, in the area most affected by venous hypertension in a 2-week registry. Elastic compression, compression plus Viatromb (lyposomal spray gel heparin), Lioton (gel including heparin), and Viatromb alone were compared. Subjects were evaluated for laser Doppler flux, transcutaneous partial pressure of oxygen (TcPO2), and partial pressure of carbon dioxide (PCO2) and CVI analogic symptom scale. In the Viatromb groups (B and D), significant decreases in laser Doppler flux, PCO2, and CVI score were observed. The decrease was proportionally more important in the elastic compression plus Viatromb group. Partial pressure of oxygen (PO2) was significantly increased. No significant changes were observed in the Lioton group. There was a good effect for compression only. These differences are significant, as they can be observed even in small groups (10-15 patients). No treatment side effects were observed, and compliance and tolerability were very good.

Control of edema in hypertensive subjects treated with calcium antagonist (nifedipine) or angiotensin-converting enzyme inhibitors with Pycnogenol.

The presence of edema in different phases and stages of essential hypertension may be due to antihypertensive treatment. Some drugs may cause edema by inducing vasodilatation, increasing the capillary exchange surface and capillary filtration. Pycnogenol has an important anti-edema effect in diabetic microangiopathy and chronic venous insufficiency. This 8-week study evaluated capillary filtration in 2 comparable treatment groups with hypertension treated with a calcium antagonist (nifedipine) or angiotensin-converting enzyme inhibitor to define its efficacy in preventing edema caused by antihypertensives. A significant decrease in filtration was observed in the Pycnogenol groups. Pycnogenol controls this type of edema, it helps to prevent and limit long-term damage in the microcirculation in hypertensive patients, and allows the dose of anti-hypertensive drugs to be reduced in most patients.

Circulating endothelial cells in venous blood as a marker of endothelial damage in chronic venous insufficiency: improvement with venoruton.

Damage to endothelial cells is common in vascular disorders and in reactions associated with transplantation. An elevated number of circulating endothelial cells indicates the extent of endothelial damage in a variety of disorders. In chronic venous insufficiency (CVI), the number of endothelial cells is abnormally increased, and this can be considered an important indication of endothelial damage. A group of 23 subjects with two levels of CVI (severe and very severe with previous ulcerations) with an increased endothelial cell count (seen by microscopy) was studied and treated for 4 weeks with oral Venoruton (0-[beta-hydroxyethyl]-rutosides) (1 g/day) to evaluate the effects of treatment on the circulating endothelial cells in blood taken from a peripheral leg vein. The controls comprised two groups with comparable age and sex distribution, one of healthy individuals and one of CVI subjects. After 4 weeks, a significant decrease was noted in endothelial cells both in subjects with CVI and in those with very severe CVI with previous ulcerations. This study suggests that endothelial cells may play a significant role in venous disease, being both an indication of severe disease and a further problem in itself. The use of Venoruton appears to decrease the number of circulating endothelial cells. This suggests an important role of this compound in protecting the endothelium and offers new potentially important therapeutic options that are not limited only to venous disease.

[Laparoscopic colorectal surgery: is the "learning curve" necessary?]. / Chirurgia colo-rettale laparoscopica: e necessaria la "curva di apprendimento"?

AIM OF THE STUDY: To present the early experience of the Authors' division in the field of colorectal laparoscopic surgery, in order to evaluate the so-called "learning curve". MATERIALS AND METHOD: From February 2003 to May 2004, we have performed 220 surgical procedures for colorectal pathology: 63 were conducted by a laparoscopic approach with 10 patients who, converted to a laparotomic procedure in theatre, were not taken under consideration. The present work is thus based on a population of 53 patients, 27 men and 26 women, at a median age of 64.4 y.o. (range 42-81). RESULTS: We performed 1 total colectomy, 24 right hemicolectomy, 1 resection of the splenic flexure, 12 left hemicolectomy (in 1 case a left hepatic lobectomy was associated), 11 anterior resection of the rectum, 1 Hartmann' sigmoid resection and 3 abdomino-perineal resection. Mean operative time was 200.34 +/- 64.17 min, while the mean hospital stay was 6.44 +/- 2.68 days. Peri-operative mortality was 0%, 30-days mortality was 1/53 patients (9%) while morbidity was 5/53 patients (9.4%): in 2 cases reintervention was necessary. DISCUSSION: From the evaluation of the results, we found some significant data: first, the conversion rate was similar to those reported by other authors, so also the mortality and morbidity rates. CONCLUSIONS: The advantages of the laparoscopic technique, indirectly documented by shorter in-hospital stay. At least for patients submitted to right or left hemicolectomy without complications (5.5 e 5.7 days, respectively), could be seen also after only a 1 year of activity. As far as the "learning curve" is concerned, dividing our activity into 3 times, we verified a progressive shortening of the operative time and, at least for the patients submitted to a right emicolecomy, also of the morbidity rates.