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Introduction Many diseases can imitate inflammatory bowel disease [IBD] clinically and pathologically. This review outlines the differential diagnosis of IBD and discusses morphological pointers and ancillary techniques that assist with the distinction between IBD and its mimics. Methods European Crohn’s and Colitis Organisation [ECCO] Topical Reviews are the result of an expert consensus. For this review, ECCO announced an open call to its members and formed three working groups [WGs] to study clinical aspects, pathological considerations, and the value of ancillary techniques. All WGs performed a systematic literature search. Results Each WG produced a draft text and drew up provisional Current Practice Position [CPP] statements that highlighted the most important conclusions. Discussions and a preliminary voting round took place, with subsequent revision of CPP statements and text and a further meeting to agree on final statements. Conclusions Clinicians and pathologists encounter a wide variety of mimics of IBD, including infection, drug-induced disease, vascular disorders, diverticular disease, diversion proctocolitis, radiation damage, and immune disorders. Reliable distinction requires a multidisciplinary approach.

Background: Lymphocele is a common complication after kidney transplantation, which does not require treatment unless it is symptomatic. In this study, we aimed to evaluate the incidence, clinical symptoms, treatment choices, and success of different treatment methods of symptomatic lymphocele. Materials and Methods: We evaluated 168 patients who had kidney transplantation between January 2012 and January 2020. Patients with decreased kidney functions due to lymphocele formation during the clinical follow-up were included in the study. External drainage catheter was placed in all patients, except one. In case of treatment failure with external drainage, laparoscopic fenestration guided by intraperitoneal ultrasonography was performed. Clinical symptoms and success rates of treatments were evaluated. Results: Symptomatic lymphocele requiring interventional treatment was detected in 15 (8.9%) of 168 renal transplant patients. All of the symptomatic lymphocele cases had increased serum creatinine levels, whereas 10 had decreased urine volume, 4 had abdominal discomfort, and 2 had ipsilateral lower extremity edema. External drainage catheter was placed as the first-line treatment in 13 patients. In 6 cases, due to treatment failure with external drainage and in 2 patients as a first-choice treatment, laparoscopic fenestration was performed. No lymphocele recurrence was observed during follow-up. Conclusion: Among various methods defined in the treatment of lymphocele, use of laparoscopic fenestration is increasing because of its high success rate and advantages over other methods. Intraperitoneal ultrasound-guided laparoscopic fenestration is a useful and safe method that can be performed as a first-choice treatment since it eliminates the risk of organ injury or bleeding.

Background: Approximately 25% of patients after bariatric surgery either do not lose enough weight or regain a considerable amount of weight, both are referred to as nonresponse. This study aimed to describe the added value of a multidisciplinary approach on treatment strategies in patients with nonresponse.Materials and Methods: The primary outcome of this retrospective cohort study was the initiated treatment by the multidisciplinary team (MDT). Outcomes were described separately for patients with primary (i.e., = 50% EWL followed by >5% regain).Results: Of the 83 included patients, 10 patients underwent revisional surgery. A total of 73 patients received a conservative treatment as they either had not been able to change their lifestyle or due to certain behavioral factors. Conservatively treated patients stabilized in weight after 2 years (-0.9 kg +/- 5.8, n = 27), while surgically treated patients did lose weight (-12.1 kg +/- 16.9, n = 7). One patient suffered from an ulcerative stenosis at the gastroenterostomy after limb length alteration.Conclusions: a conservative treatment was the most frequently advocated treatment by the MDT. A surgical treatment resulted in successful weight loss, although only a few patients were selected for this by the MDT. A multidisciplinary approach can be beneficial for the identification of lifestyle and behavioral factors.

Background and Aims Standard coagulation tests such as prothrombin time, activated partial thromboplastin time, and international normalized ratio are determined by liver-synthesized coagulation factors. Despite an increased international normalized ratio, patients with cirrhosis are in a “rebalanced” state of hemostasis as the concomitant effect of reduced protein C, protein S, and thrombomodulin is not evaluated in standard coagulation tests. The cell-based model of hemostasis indicates additional mechanisms such as systemic inflammation, sepsis, and organ failures tip the delicate coagulation balance to an anticoagulant type in acute-on-chronic liver failure. In acute liver failure, thrombin generation and platelet function remain intact despite a marked prolongation in prothrombin time. We aimed to explain the principles, application, and utility of viscoelastic tests such as thromboelastography, rotational thromboelastometry, and Sonoclot. Methods We reviewed the available literature from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trial with the search terms 'coagulation', 'cirrhosis', 'acute-on-chronic liver failure', 'thromboelastography', 'thromboelastometry' and 'sonoclot' for cross sectional studies, cohort studies and randomized trials Results The point-of-care viscoelastic tests provide actionable targets for correcting the coagulation defect in a patient with bleeding and provide evidence-based algorithms for use in liver disease. A limitation of these tests is the inability to assess vessel injury and endothelial elements. Conclusion Global coagulation tests provide a comprehensive estimate of coagulation in vitro; however, their use has only been validated in the setting of liver transplantation. Newer guidelines for hemostatic resuscitation are now accepting these POC tests, but additional data are required to validate their use as standard of care.

Background Multidrug-resistant organisms (MDROs) are a reality that can alter the paradigm of treatment and prevention of infection in patients with liver cirrhosis (LC). Objective Identify risk factors for the occurrence of MDROs in patients with LC. Patients and methods Prospective study from October 2017 to March 2018 in consecutively hospitalized patients with decompensated LC with infection. Blood, urine and ascitic fluid cultures were analyzed. A p-value ≤0.05 was considered statistically significant. Results MDROs isolated in 18 of 52 episodes of infection. MDROs were associated with the use of proton pump inhibitors (PPIs) (p = 0.0312), antibiotic therapy in the last 90 days (p = 0.0033) and discharge within preceding 30 days or current hospitalization above 48 h (p = 0.0082). There was higher 90-day mortality in patients with MDROs infection (71.4% versus 35.7%, p = 0.0316). Conclusion MDROs infections were prevalent in this cohort and associated with 90-day mortality. Use of PPIs and antibiotics increased the risk of MDROs infections, suggesting that its prescription should be restricted to formal indication. Hospitalization was associated with the onset of MDROs, so LC patients should stay at the hospital the least possible. It is relevant to investigate other factors predisposing to the emergence of these microorganisms, in order to prevent it.

Resumen Introduccion y objetivos La colangitis esclerosante primaria (CEP) es una enfermedad hepatica colestasica rara, que tipicamente afecta a varones de mediana edad con colitis ulcerosa (CU). No obstante, estudios recientes apuntan a cambios epidemiologicos. Nuestro objetivo es determinar si la epidemiologia, presentacion clinica y curso evolutivo de pacientes con CEP seguidos en un centro de referencia se asemejan a lo descrito en la literatura. Pacientes y metodos Busqueda retrospectiva de pacientes con diagnostico de CEP atendidos en nuestro centro entre los anos 2000 y 2019. Resultados Cohorte de 55 pacientes (media de edad: 37 anos), el 44% mujeres, afectos de CEP, el 79% de ducto grande. Casi dos tercios fueron diagnosticados a partir de 2011. En el momento del diagnostico, un 63% de los pacientes se encontraba asintomatico. La mediana de tiempo desde la sospecha hasta el diagnostico fue de 2 anos. Un 34% desarrollo cirrosis en el seguimiento, y un 25% requirio trasplante hepatico (TH) tras una media de tiempo de 7 anos; entre estos, la enfermedad recurrio en un 46%. Un 45% presentaba una enfermedad inflamatoria intestinal (EII), sobre todo CU. Si bien no se alcanzo significacion estadistica, la CEP en mujeres se caracterizo por mayor tasa de presentacion asintomatica, mayor asociacion con CU frente a otras formas de EII, asi como cirrosis al diagnostico y necesidad de TH con mayor frecuencia que los varones. Conclusiones La epidemiologia de la CEP esta cambiando. El numero de mujeres afectas es mayor al descrito previamente, objetivandose un aumento reciente de la incidencia. Podrian existir diferencias entre sexos en la forma de presentacion y evolucion que deberan confirmarse en estudios posteriores.

Nonalcoholic fatty liver disease (NAFLD) affects more than 25% of the adult population worldwide and is associated with significant clinical and economic burden.1 However, heterogeneous definitions and inaccurate terminology contribute to variations in prevalence estimates and may not comprehensively incorporate complex metabolic dysfunctions that exist. An international expert panel consensus proposed updated nomenclature, metabolic dysfunction-associated fatty liver disease (MAFLD), and associated criteria to more accurately capture this complex multisystem metabolic disorder.2 Although it has not replaced NAFLD, the term MAFLD has been positively received given it more comprehensively incorporates the metabolic derangements that contribute to risk of fatty liver and it may be more practical for clinicians to identify patients with fatty liver.3 We describe prevalence of MAFLD among US adults based on these recently proposed nomenclature and definition.2.

Background Anastomotic leakage is a fearsome complication in rectal surgery. Surgeons perform the classic air-leak test, although its real effectiveness is still debated. The aim of this study was to describe a personal technique of reverse air leak test in which low colorectal anastomosis were assessed transanally through the intra-rectal irrigation of a few mL of saline solution. Methods From October 2014 to November 2019 eleven patients with low rectal cancer (Type 1 in Roullier classification) were included in this study. At the beginning of the procedure, a circular anal dilator (CAD) was inserted into the anus. A side-to-end colorectal anastomosis was performed. A few mL of saline solution were injected into the rectum and the entire anastomotic line was directly explored. The appearance of bubbles was considered as an anastomotic defect and repaired with an interrupted suture. A fluorescence angiography after intravenous injection of Indocyanine green was performed in order to evaluate the perfusion of the anastomosis. Results In 4 cases (36.3%) the reverse air-leak test was positive. The defect was repaired and a confirmation test was performed. In all patients, near-infrared evaluation showed not perfusion defect (grade 0) in low colorectal anastomosis. No post-operative fistula was detected in cohort study. A protective stoma was performed in 10 patients. At 90-days there were no complications and stoma closure was performed as planned. Conclusion The reverse air-leak test is a simple, feasible and effective procedure to identify anastomotic leak in low colorectal anastomoses.

Background Miscarriage occurs in 10-15% of pregnancies and recurrent pregnancy loss (RPL) occurs in 1% of couples hoping for a child. Various risk factors, such as thrombophilia, uterine malformation, and embryonic chromosomal aberration cause RPL. We hypothesized that antithrombotic therapy for RPL patients with thrombophilia would reduce miscarriage due to thrombophilia, which would reduce the total miscarriages and result in a relative increase in miscarriage due to embryonic chromosomal aberrations. In this study, we investigated the incidence of chromosomal aberrations in products of conception in RPL patients with and without antithrombotic therapy. Methods We performed a single-center, retrospective review of cases diagnosed as miscarriage with embryo chromosome analysis between July 1, 2000, and May 31, 2019. Rates of chromosomal aberration were compared between RPL patients with and without thrombophilia or antithrombotic therapy. Results One hundred and-ninety RPL cases were analyzed. The average age was 37.4 ± 4.3 years, and the average number of previous pregnancy losses was 2.2 ± 1.1. The overall chromosomal aberration rate was 67.4% (128/190). There was no difference in the chromosomal aberration rate between the factors for RPL, with or without thrombophilia, and antithrombotic therapy. Only advancing maternal age had significant correlation to increased embryo chromosomal aberration rates. Conclusions With or without antithrombotic therapy, miscarriage was caused by embryonic chromosome abnormalities at a certain rate. Antithrombotic therapy in RPL patients with thrombophilia may reduce abortions due to thrombophilia, which may also normalize the rate of embryonic chromosome aberrations in the subsequent miscarriages.

Amyloid light-chain (AL) cardiac amyloidosis is known to result in restrictive cardiomyopathy, which has a poor prognosis. Although electrocardiography (ECG) is useful for its diagnosis and management, there are few reports on the long-term follow-up of electrocardiographic changes. The patient in the present case was a 62-year-old woman who visited our hospital due to palpitation and lower leg edema. A chest radiograph showed cardiac enlargement, and ECG revealed sinus rhythm, first-degree atrioventricular block, low QRS voltage in the limb leads and a pseudomyocardial infarction pattern in the precordial leads. Echocardiography revealed left ventricular hypertrophy with systolic and diastolic dysfunction. Immunoelectrophoresis demonstrated M-protein (IgGλ), and bone marrow biopsy implied IgGλ-type plasmacytoma. Myocardial biopsy findings were compatible with cardiac amyloidosis. Based on these findings, we diagnosed the patient with AL cardiac amyloidosis. Melphalan-prednisolone (MP) therapy was performed in conjunction with treatment for non-sustained ventricular tachycardia and congestive heart failure. Two years and four months later, the sinus rhythm converted to atrial tachycardia. At a follow-up examination at four years and eight months, right branch block appeared. Then degree of intraventricular conduction was worsened, and the low voltage of the limb leads was not observed. Seven years after the diagnosis, she was eventually hospitalized for the treatment of pneumonia and heart failure with tachycardia. On the seventh day of hospitalization, heart rhythm was changed to atrial stand-still with escaped ventricular rhythm and died of cardiac arrest. These ECG changes may provide valuable information regarding the pathophysiological changes that occur in AL cardiac amyloidosis.

Background PIK3CA is associated with tumor progression, and the prevalence of its mutation is high in breast cancer. Liquid biopsy offers convenient, non-invasive, and real-time insight into genetic alternation. In this study, we attempted to detect PIK3CA mutations in breast cancer patients through liquid biopsy. Methods We recruited patients with histologically confirmed breast cancer with distant metastases between April 2020 and September 2020. Circulating DNA was extracted from plasma (ctDNA) and exosomes (exoDNA). PIK3CA mutations (exons 9 and 20) were analyzed by droplet digital PCR. Results Of a total of 52 patients recruited, 16 had PIK3CA mutations in their tumor tissue or blood, which comprised 9 with exon 9 mutations (E542K and E545K) and 8 with exon 20 mutations (H1047L and H1047R). In 8 (15%) of the 52 patients, PIK3CA mutations were detected by liquid biopsies using ctDNA in 5 (9%), exoDNA in 6 (11%), and both ctDNA and exoDNA in 3 (6%). Of the 8 patients with PIK3CA mutations detected by liquid biopsies, 3 had no PIK3CA mutations in the primary tumors. Conclusions PIK3CA mutations can be detected using liquid biopsy even in patients with no PIK3CA mutations in their primary tumors; thus, combination analysis using tissue and liquid biopsies can provide clinically useful information for patients with breast cancer.

BACKGROUND & AIMS Cold snare polypectomy (CSP) has become the standard resection method for small colorectal polyps (

Background and aims Inflammatory bowel diseases (IBD) are chronic conditions that may be accompanied by autoimmune liver disease (AILD), most commonly primary sclerosing cholangitis (PSC). The objective of this study was to evaluate the behaviour of patients with IBD associated with AILD and compare a PSC group with a non-PSC group. Methods Medical records of patients with IBD associated with PSC, autoimmune cholangitis, primary biliary cholangitis, small-duct PSC, autoimmune hepatitis (AIH) and overlapping syndromes were assessed. Results Fifty-four patients were included: 48 (88.9%) had ulcerative colitis and six (11.1%) had Crohn's disease; 35 (64.8%) had PSC and 19 (35.2%) did not have PSC. There was no difference in outcomes (surgical treatment for IBD, liver transplantation or death) between the groups. Time since the diagnosis of IBD was associated with surgical treatment of IBD (p = 0.041; OR: 1.139, 95% CI: 1.006–1.255). Time since the diagnosis of AILD (p = 0.003; OR: 1.259, 95% CI: 1.1–1.396), as well as portal hypertension at diagnosis (p = 0.014; OR: 18.22, 95% CI: 1.815–182.96), were associated with liver transplantation. In addition, previous diagnosis of AIH was associated with de novo IBD (p = 0.012; OR: 7.1, 95% CI: 1.215–42.43). Conclusion Both groups had similar disease behaviour. A longer time since the diagnosis of IBD increased the risk for surgical treatment (13.9%/year). A 25.9%/year increase in liver transplantation was observed after the diagnosis of AILD, which was increased 18.22 times by the presence of portal hypertension. In addition, the diagnosis of AIH was associated with an increase in the number of diagnoses of de novo IBD (7.1).

Background & Aims The tumor microbiome of patients with pancreas ductal adenocarcinoma (PDAC) includes bacteria normally present in the upper gastrointestinal tract. If the predominant source of intratumoral bacteria in patients with PDAC is retrograde migration from the duodenum, duodenal fluid could be a representative biospecimen for determining microbiome profiles of patients with PDAC or at risk of developing PDAC. Methods We performed a case-control study comparing bacterial and fungal (16S and 18S rRNA) profiles of secretin-stimulated duodenal fluid collections from 308 patients undergoing duodenal endoscopy including 134 normal pancreas control subjects, 98 patients with pancreatic cyst(s) and 74 patients with PDAC. Results Alterations in duodenal fluid microbiomes with diminished alpha diversity were significantly associated with age >70 and proton pump inhibitor use. Patients with PDAC had significantly decreased duodenal microbial alpha diversity compared with age-matched control subjects with normal pancreata and those with pancreatic cyst(s). There was evidence of enrichment of Bifidobacterium genera in the duodenal fluid of patients with PDAC compared with control subjects and those with pancreatic cyst(s). There were also enrichment of duodenal fluid Fusobacteria and Rothia bacteria among patients with PDAC with short-term survival. Duodenal fluid microbiome profiles were not significantly different between control subjects and patients with pancreatic cyst(s). Conclusion Patients with PDAC have alterations in their duodenal fluid microbiome profiles compared with patients with pancreatic cysts and those with normal pancreata. ClinicalTrials.gov , Number: NCT02000089

Objective The aim of this study was to evaluate oncological outcome for patients with and without anastomotic leakage after colon or rectal cancer surgery. Summary of background data The role of anastomotic leakage in oncological outcome after colorectal cancer surgery is still topic of debate and impact on follow-up and consideration for further treatment remains unclear. Methods Patients included in the international, multicenter, non-inferior, open label, randomized, controlled trials COLOR and COLOR II, comparing laparoscopic surgery for curable colon (COLOR) and rectal (COLOR II) cancer with open surgery, were analyzed. Patients operated by abdominoperineal excision were excluded. Both univariate and multivariate analyses were performed to investigate the impact of leakage on overall survival, disease-free survival, local and distant recurrences, adjusted for possible confounders. Primary endpoints in the COLOR and COLOR II trial were disease-free survival and local recurrence at 3-year follow-up, respectively, and secondary endpoints included anastomotic leakage rate. Results For colon cancer, anastomotic leakage was not associated with increased percentage of local recurrence or decreased disease-free-survival. For rectal cancer, an increase of local recurrences (13.3% vs 4.6%; hazard ratio 2.96; 95% confidence interval 1.38-6.34; P = 0.005) and a decrease of disease-free survival (53.6% vs 70.9%; hazard ratio 1.67; 95% confidence interval 1.16-2.41; P = 0.006) at 5-year follow-up were found in patients with anastomotic leakage. Conclusion Short-term morbidity, mortality, and long-term oncological outcomes are negatively influenced by the occurrence of anastomotic leakage after rectal cancer surgery. For colon cancer, no significant effect was observed; however, due to low power, no conclusions on the influence of anastomotic leakage on outcomes after colon surgery could be reached. Clinical awareness of increased risk of local recurrence after anastomotic leakage throughout the follow-up is mandatory. Trial registration Registered with ClinicalTrials.gov, number NCT00387842 and NCT00297791.

We provide a unique case of haemorrhagic shock complicating a corticosteroid-resistant diffuse ulcerative enteritis in a patient treated with a combination of an anti CTLA-4 and an anti PD-1 for metastatic melanoma. Immunotherapy has changed the perspective for the management of patients with metastatic melanoma but are also responsible for digestive complications mainly represented by immunomediated colitis. Digestive bleeding is common in patients with extensive colonic lesions but has never been described in enteritis independent of colitis. The patient with acute intestinal obstruction related ileitis without evidence of stricture on imaging and then had a gastro-intestinal bleed. In the absence of haemorrhagic lesions on upper gastrointestinal endoscopy, colonoscopy and CT angiography, a surgical exploration with enteroscopy was performed. This revealed an extensive ulcerated jejunoileitis, with active bleeding, within a Meckel's diverticulum. Management included resection of the Meckel diverticulum with a transient double barrel ileostomy. Two infliximab infusions were given due to persistent bleeding. We observed a dramatic improvement after infliximab treatment with complete cessation of bleeding and no further need for transfusions. A complete mucosal healing has been achieved on enteroscopy at 3 months with disappearance of histological inflammatory lesions. This observation suggests that infliximab represents a therapeutic option in severe enteritis and may be as effective as in more moderate immune-mediated enterocolitis.

Background and Aims We conducted a retrospective cohort study comparing the risk of serious infections between patients treated with tumor necrosis factor-a (TNFa) antagonists vs. vedolizumab in patients with inflammatory bowel diseases (IBD). Methods Using an administrative claims database, we identified patients with IBD who were new-users of either TNFa antagonists or vedolizumab between 2014-2018 and had insurance coverage for at least 1y before and after treatment initiation. We compared the risk of serious infections (infections requiring hospitalization) between patients treated with vedolizumab or TNFa antagonists using marginal structural Cox proportional hazard models adjusted for baseline disease characteristics, healthcare utilization, comorbidities, and time-varying use of corticosteroids, immunomodulators and opiates. Results We included 4881 patients treated with TNFa antagonists (age, 41 ± 15y, 60% with Crohn’s disease [CD]) of whom 434 developed serious infections over 5786 person-year [PY] follow-up, and 1106 patients treated with vedolizumab (age, 44 ± 16y, 39% with CD) of whom 86 developed serious infections over 1040-PY follow-up. Vedolizumab was associated with 46% lower risk of serious infections as compared with TNFa antagonists in patients with ulcerative colitis (HR,0.54 [95% CI,0.35-0.83), but no significant differences were observed in patients with CD (HR,1.30 [0.80-2.11]). Vedolizumab was associated with lower risk of extra-intestinal serious infections in patients with UC, but higher risk of gastrointestinal serious infections in patients with CD. Conclusions In an observational study of patients with IBD, vedolizumab was associated with lower risk of serious infections as compared with TNFa antagonists, in patients with UC, but not in patients with CD.

Background Several observational studies on Tofacitinib (TOFA) in ulcerative colitis (UC) have been published over the last 2 years. Aims To estimate effectiveness and safety of TOFA arising from real-world experience. Methods PubMed Central/Medline and Embase were systematically searched for real-world observational studies on TOFA for the treatment of UC through November 2020. Results Seven studies comprising 759 patients met the inclusion criteria. The pooled estimate rates were 49% for clinical response, 40% for clinical remission, and 34% for corticosteroid-free clinical remission at induction, while the rates of endoscopic response and endoscopic remission were 37% and 19%, respectively. At maintenance, the pooled estimate rates of clinical response, clinical remission, and corticosteroid-free clinical remission were 36%, 35%, and 24%, respectively. The pooled estimate of incidence rate of adverse events was 53.0 per 100 person-years (PY), while the pooled estimate of incidence rate of withdrawal of TOFA due to adverse events was 9.3 per 100 PY, with a pooled rate of infections of 17.6 per 100 PY. Conclusions Cumulative analysis of data from real-world studies confirmed the good efficacy of TOFA in UC shown by randomized controlled trials for both induction and maintenance, while the safety profile was consistent with previous reports.

Rates of pregnancies affected by nonalcoholic fatty liver disease (NAFLD) in the United States have nearly tripled in the last decade and NAFLD confers increased perinatal risks, such as hypertensive complications, postpartum hemorrhage, and preterm birth.1 Rates of cirrhosis in pregnancy are also rising,2 although estimates specific to NAFLD cirrhosis are lacking. Whether NAFLD cirrhosis confers differential perinatal risks than other causes of cirrhosis in pregnancy is also unknown.

BACKGROUND: Quality of life (QOL) data following pediatric fundoplication for gastroesophageal reflux disease (GERD) are rare. Present study assessed the QOL in neurologically non-impaired children before and after laparoscopic hemifundoplication (LHF) in comparison to healthy controls. METHODS: PedsQL™ questionnaires assessed data on gastrointestinal symptoms (GIS) and general well-being (GWB) were compared in a propensity score-matched analysis (60 patients' pairs for time-point of surgery and 51 for follow-up). RESULTS: Preoperatively, the LHF group had more GIS (72.2 ± 53.9 vs. 38.8 ± 31.6; p

Alcoholic hepatitis (AH) is a severe condition with poor short-term prognosis. Specific treatment with corticosteroids slightly improves short-term survival but is associated with infection and is not used in many centers. A reliable method to identify patients who will recover spontaneously will minimise the numbers of patients who experience side effects of available treatments.We analysed the trajectory of serum bilirubin concentration over the course of hospital admissions in patients with AH to predict spontaneous survival and the need for treatment.data from 426 patients were analysed. Based on bilirubin trajectory, patients were categorized into three groups: 'fast fallers' (bilirubin0.8 x admission value at day 7), 'static' (bilirubin of0.9 -1.2 x admission value) and 'rapid risers' (bilirubin of ≥1.2 x admission bilirubin). Fast fallers had significantly better 90-day survival compared to other groups (log rank p.001), and showed no benefit of corticosteroid therapy (OR for survival at 28 days of treatment, 0.94, 95% CI 0.06 - 8.41). These findings remained even amongst patients with severe disease based on initial DF, GAHS or MELD scores.We present an intuitive method of classifying patients with AH based on the trajectory of bilirubin over the first week of admission. It is complimentary to existing scores that identify candidates for corticosteroid treatment or assess response to treatment. This method identifies a group of patients with AH who recover spontaneously and can avoid corticosteroid therapy.

BACKGROUND & AIMS: A non-endoscopic approach to Barrett’s esophagus (BE) surveillance after radiofrequency ablation (RFA) would offer a less invasive method for monitoring. We assessed the test characteristics and cost-effectiveness of the Cytosponge® in post-RFA patients. METHODS: We performed a multicenter study of dysplastic BE patients after at least one round of RFA. A positive Cytosponge® before endoscopy was defined as intestinal metaplasia (IM) on cytological assessment and/or TFF3 immunohistochemistry. Sensitivity, specificity, and receiver operator characteristic (ROC) curves were calculated. Multivariable regression was used to estimate the odds of a positive Cytosponge® in BE. A microsimulation cost-effectiveness model was performed to assess outcomes of various surveillance strategies: endoscopy-only, Cytosponge®-only, and alternating endoscopy/Cytosponge®. RESULTS: Of 234 patients, Cytosponge® adequately sampled the distal esophagus in 175 (75%). Of the 142 with both endoscopic and histologic data, 19 (13%) had residual/recurrent BE. For detecting any residual Barrett’s, Cytosponge® had a sensitivity of 74%, specificity of 85%, accuracy of 84%, and ROC curve showed an area under the curve of 0.74. The adjusted odds of a positive Cytosponge® in BE were 17.1 (95% CI: 5.2–55.9). Cytosponge®-only surveillance dominated all the surveillance strategies, being both less costly and more effective. Cytosponge®-only surveillance required

Background & Aims Porto-sinusoidal vascular disease (PSVD) was recently proposed as novel clinical entity characterized by typical histological changes with or without portal hypertension (PH) in the absence of cirrhosis. Thus, we aimed to describe clinical characteristics and the outcome of PSVD patients and to compare these to patients meeting traditional idiopathic non-cirrhotic portal hypertension (INCPH) criteria. Methods Patients undergoing liver biopsy (baseline) ±hepatic venous pressure gradient (HVPG) measurement at the Vienna General Hospital between 2000-2019 were screened for PSVD and INCPH criteria. Results 91 patients were diagnosed with PSVD of which 28 (30.8%) also fulfilled INCPH criteria (INCPH+/PSVD+). Specific histological and specific clinical PH signs were found in 72 (79.1%) and 54 (59.3%) patients, respectively. INCPH+/PSVD+ showed higher Child-Pugh-scores (7±2 vs 6±1 points; P = .002) and a higher prevalence of decompensation (57.1% vs 28.6%; P = .009) than INCPH-/PSVD+ patients. Importantly, hepatic decompensation after three years (3Y) occurred in 11.2% of PSVD patients with specific clinical signs of PH, while no decompensation occurred in patients with only specific histological or with unspecific clinical/histological signs (P = .002). When categorizing by INCPH definition, 3Y decompensation was 13.4% in INCPH+/PSVD+ and 3.8% in INCPH-/PSVD+ (P = .120). While overall mortality was similar in INCPH+/PSVD+ (n = 6; 21.4%) and INCPH-/PSVD+ (n = 10; 15.9%) patients (P = .558), liver-related mortality tended to be higher in INCPH+/PSVD+ (6.9%) than in INCPH-/PSVD+ (0%; P = .078). Conclusion Novel PSVD criteria facilitate diagnosis. Compared to INCPH, clinical course of PSVD patients is more favorable. Importantly, specific signs of PH including varices and collaterals are associated with hepatic decompensation and mortality.

Introducción: El confinamiento debido a la pandemia por COVID 19 en España tuvo probablemente un importante impacto emocional en los pacientes crónicos, y por tanto en aquellos que sufren enfermedad inflaamtoria intestinal (EII) debido a su riesgo incrementado de padecer desórdenes emocionales. El objetivo: de este estudio es el de conocer como la COVID 19 ha influído a los pacientes con EII durante el período de cuarentena, haciendo especial hincapie en el nivel de estrés a través de la Escala de Estrés Percibido (PSS-10) así como en la adherencia a los tratamientos a través de la escala visual analógica (VAS). Pacientes y métodos: Estudio prospectivo, unicéntrico y observacional realizado en la Unidad de EII durante el mes de agosto de 2020. Los pacientes fueron entrevistados por teléfono. Se llevó a cabo un análisis descriptivo inicial, posteriormente se identificaron los factores relacionados con la pérdida de adherencia así como con los niveles altos-moderados de estrés a través de análisis de regresión logística multivariante. Resultados: Fueron incluidos un total de 426 pacientes con una puntuación media en la escala PSS-10 de 12 (10-16). Los niveles más altos de estrés se reportaron en aquellos pacientes que no estaban casados, las mujeres o aquellos que habían incrementado sintomatología relacionada con su EII. La adherencia al tratamiento no se asoció con el nivel de estrés basado en el cuestionario PSS-10. Conclusiones: A pesar de que el período de cuarentena por COVID-19 haya podido tener un importante papel en el impacto emocional de la población española con EII, los pacientes con EII tuvieron en general nvieles bajos se´gun el cuestionario PSS-10.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the treatment of choice for obesity with gastroesophageal reflux disease (GERD). There are few reports showing objective data...

Lumboperitoneal or ventriculoperitoneal shunt insertion is a standard therapy for hydrocephalus that diverts cerebrospinal fluid from the subarachnoid space into the peritoneal cavity. Gastrointestinal perforations due to this procedure occur rarely; however, accepted treatment strategies have not yet been established. Hence, the most common treatment approaches are open surgery or spontaneous closure without endoscopy. We report the case of a small intestinal perforation in a 73-year-old-woman that occurred after the insertion of a lumboperitoneal shunt. A positive cerebrospinal fluid culture and high cerebrospinal fluid white blood cell count indicated a retrograde bacterial infection, and computed tomography revealed that the peritoneal tip of the shunt catheter was located in the lumen of the gastrointestinal tract. We repaired the perforation endoscopically using an over-the-scope clip, and the patient’s recovery was uneventful. Use of an over-the-scope clip could be an effective and minimally invasive treatment for intestinal perforations caused by lumboperitoneal or ventriculoperitoneal shunt insertion.

Background/Aims: Helicobacter pylori (H. pylori) seroconversion may occur during screening for gastric cancer. Our study aimed to assess the number of seroconverted subjects with H. pylori and their results in follow-up tests.Methods: Data were consecutively collected on subjects who were H. pylori-seronegative and presented for gastric cancer screening. Subjects who were followed up using the same serology test and pepsinogen (PG) assays on the day of endoscopy were included in the study.Results: During the follow-up of 57.7±21.4 months, 61 (15.0%) of 407 seronegative subjects showed seroconversion. H. pylori infection was detected in six (9.8%) of 61 seroconverted subjects. A diffuse red fundal appearance, with a significant increase in the Kyoto classification scores for gastritis, was observed in the infected subjects (p

Background/Aims: Infliximab (IFX) has been used to induce and maintain remission in patients with severe steroid-refractory ulcerative colitis (UC). Long-term use of biologics in developing countries is limited by high cost and frequent side effects. An optimal maintenance strategy in these patients needs to be established.Methods: A retrospective analysis of maintenance of clinical remission with combination of azathioprine (AZA) and 5-aminosalicylates (5-ASA) in patients with severe steroidrefractory UC where IFX (5 mg/kg intravenously at weeks 0, 2, 6) had been used only as an induction therapy was done at 2 centers in India. Primary outcome was the proportion of patients maintaining corticosteroid-free sustained clinical remission (SCR) at the end of study period. Rates of relapse and cost of therapy were also analyzed.Results: Of the 137 patients who received rescue IFX induction therapy, 77 (56.2%) achieved clinical remission (mean age 34.81 ± 13.32 years, 68.83% males, median follow-up 4 years, range 3 months to 6 years) and were included. Cumulative corticosteroid-free SCR was maintained in 68%, 59%, 42%, and 35% patients at 1, 2, 4, and 6 years respectively. Sixty-seven relapses were observed in 33 patients. Majority of the relapses (45/67, 67.16%) occurred within first 2 years of follow-up. Two relapses were managed with re-induction with IFX, one required colectomy, whereas all other responded to repeat course(s) of corticosteroids. Annual per capita maintenance therapy with 5-ASA and AZA was cheaper by US$ 4,526 compared to maintaining remission with IFX.Conclusions: Clinical remission achieved with IFX induction therapy in severe steroid-refractory UC can be sustained over long time with a combination of AZA and 5-ASA.

The role of gut microbiome-intestinal immune complex in the development of colorectal cancer and its progression is well recognized. Accordingly, certain microbial strains tend to colonize or vanish in patients with colorectal cancer. Probiotics, prebiotics, and synbiotics are expected to exhibit both anti-tumor effects and chemopreventive effects during cancer treatment through mechanisms such as xenometabolism, immune interactions, and altered eco-community. Microbial modulation can also be safely used to prevent complications during peri-operational periods of colorectal surgery. A deeper understanding of the role of intestinal microbiota as a target for colorectal cancer treatment will lead the way to a better prognosis for colorectal cancer patients.

Обстежено 129 хворих на гострий панкреатит. Досліджено показники інтенсивності вільнорадикального окислення, перекисного окислення ліпідів, антиоксидантної активності плазми крові, тяжкість проявів синдрому системної запальної відповіді та органної дисфункції/недостатності залежно від наявності в комплексі інтенсивної терапії препаратів з антиоксидантною та антигіпоксантною активністю. Виявлено, що зростання тяжкості синдрому системної запальної відповіді асоціюється з підвищенням вмісту маркерів оксидативного стресу в сироватці крові. Включення антиоксидантів (мексидол, аскорбінова кислота) в інтенсивну терапію пацієнтів із гострим панкреатитом дозволяє знизити ступінь проявів оксидативного стресу, сприяє зменшенню проявів синдрому системної запальної відповіді та частоти органних дисфункцій.

Актуальність. У комплексному лікуванні інфаркту міокарда (ІМ), поєднаного з неалкогольною жировою хворобою печінки (НЖХП), актуальним є застосування лікарських засобів із протективними властивостями. Мета дослідження — вивчити ефективність Тіотриазоліну та препарату знежирених збагачених соєвих фосфоліпідів у комплексному лікуванні хворих у гострому періоді ІМ, поєднаного зі стеатозом печінки або неалкогольним стеатогепатитом. Матеріали і методи. Обстежено 47 хворих із гострим ІМ із зубцем Q, поєднаним із НЖХП. Дослідження електричної активності серця проводилося на вдосконаленому поліграфі з реєстрацією електро- та векторкардіограми до і після тритижневої терапії базисними препаратами 16 хворих (13 чоловіків і 3 жінок, середній вік — 60,50 ± 3,74 року), із доданням Тіотриазоліну — 16 хворих (8 чоловіків і 8 жінок, середній вік — 62,94 ± 2,71 року), Тіотриазоліном та препаратом знежирених збагачених соєвих фосфоліпідів у комбінації з базисною терапією — 15 хворих (10 чоловіків і 5 жінок) віком від 36 до 75 років (середній вік — 60,00 ± 3,36 року). Результати. Під час лікування базисними препаратами спостерігалося подальше зменшення електрорушійної сили серця з уповільненням проведення імпульсу та порушенням процесів пізньої реполяризації в міокарді шлуночків і передсердь за зменшення зони пошкодження в лівому шлуночку й перевантаження передсердь. Одночасне застосування Тіотриазоліну та базисних препаратів спричинило мінімальні позитивні зрушення в електрорушійній силі серця. Крім того, відзначалося збільшення зони ішемії за рахунок зменшення зони пошкодження міокарда, більш виражена нормалізація порожнини лівого передсердя та реєструвалася стабілізація процесів реполяризації в передсердях. Застосування лікувального комплексу, до складу якого входили базисні препарати, Тіотриазолін і препарат знежирених збагачених соєвих фосфоліпідів, сприяло знач­ному збільшенню біопотенціалів міокарда шлуночків за локального поліпшення швидкісних показників і більш вираженому відновленню кардіоміоцитів на периферії зони пошкодження. Результати впливу комбінації застосованих препаратів на показники передсердного компонента електричної активності серця вказують на значне опосередковане гемодинамічне розвантаження передсердь, спочатку поліпшене скорочувальною здатністю лівого шлуночка з подальшою нормалізацією процесів реполяризації в міокарді передсердь. Висновки. Одночасне використання Тіотриазоліну та препарату знежирених збагачених соєвих фосфоліпідів у хворих на НЖХБ в гострому періоді ІМ із зубцем Q потенціює позитивні властивості обох лікарських засобів. У зв’язку з цим можна рекомендувати призначення вищевказаних препаратів для комплексного лікування даної категорії пацієнтів.

Introduction. Interventions for inguinal hernia are the most common surgical procedures in pediatric surgery, their incidence is more than 30 % of all elective surgeries in children. Despite the prevalence of the disease in a population of children, the number of comparative studies of open and laparoscopic approaches to the treatment of inguinal hernia in children is limited. The aim of our study was to evaluate the results of laparoscopic surgery for inguinal hernias in children. Materials and methods. We observed 458 children with inguinal hernias in the period of 2011–2015. All the children underwent elective surgeries. In 120 out of the children, we have used a modified technique consisted in hydraulic dissection of the parietal peritoneum in the internal inguinal ring with the help of pre-injection into the peritoneum of 0.25% solution of novocaine. In order to objectively assess the testicular blood flow in the postoperative period in children with inguinal hernia, we have carried out ultrasound diagnostics with Doppler mapping. Results and discussion. In the analysis of the findings, we have revealed that there were 369 (80 %) cases of single-port operations. 89 children underwent multiport operation. Studies of blood flow in the testicles of children in the first group significantly showed that 26.6 % of them had a reduction of circulation in the testicle on the side of operated hernia. In the second group of patients in the postoperative period no significant deviations from the norm were revealed. Follow-up within a year after surgery showed a low number of late postoperative complications in patients. Only 12 (2.6 %) children in the first group had recurrent hernia, and in 11 (2.4 %) — hydrocele. Conclusions. 1. The majority of operated children were under 2 years of age. 2. The method of laparoscopic herniorrhaphy with hydraulic dissection is accompanied by a lower relapse rate. 3. This technology can be used in any pediatric surgery unit or urological department and can be considered a method of choice in the treatment of children with inguinal hernia.

У статті наведено огляд сучасних методів гемодинамічного моніторингу у відділенні інтенсивної терапії.

The article is devoted to the problem of viral hepatitis B and C in children with malignant hematologic disorders. Given the peculiarities of antiviral therapy of a patient with a combination of these diseases.

Introduction. Mixed cryoglobulinemia is the most common extrahepatic manifestations of chronic HCV-infection. Questions about the role of cytokines and features of liver injury in patients with chronic HCV-infection with mixed cryoglobulinemia are debatable. Objective. To determine the interrelation between changes of immunological parameters (cryoglobulins, interferon-gamma, interleukin‑4) and clinic-morphological parameters in patients with chronic hepatitis C with mixed cryoglobulinemia. Materials and methods. Eighty two patients with chronic hepatitis C were examined. Stage of liver fibrosis was determined by morphological study of hepatic samples. Concentration of interferon-gamma and nterleykin‑4 was determined by enzyme immunoassay. Cryoglobulin level was determined by spectrophotometry. Results. In patients with mixed cryoglobulinemia low levels of interferon gamma and high levels of interleukin‑4 were detected in serum, the correlation between concentration of cryoglobulins and interferon gamma (r = –0.32; p

У статті наведено власне клінічне спостереження успішного лікування фульмінантної форми гострого гепатиту В із застосуванням глюкокортикостероїдів та аналогів нуклеозидів. Особливістю клінічного випадку виявився розвиток аспергільозу легень, що потребувало хірургічного лікування. З урахуванням зникнення антигенних маркерів гепатиту В, появи серoконверсії anti-HBs у високому титрі (через 6 та 12 місяців) пацієнтка, як реконвалесцент гострого гепатиту В, була знята з диспансерного обліку.

34 men were examined, who after participating in the liquidation of the Chornobyl NPP accident developed non-alcoholic fatty liver disease. The state of antiviral defense was evaluated by the levels of immunoglobulin (Ig) G and IgM antibodies in the blood serum. In most patients with non-alcoholic steatohepatitis, who were Chornobyl NPP accident liquidators, antibodies of the IgG, but not IgM class to the persistent mixed infection with herpes simplex virus types 1 and 2, cytomegaly and Epstein-Barr were found. A positive correlation was established between the antibody titers to the herpes simplex virus types 1 and 2 (anti-HSV-1/2 IgG) and cytomegalovirus (anti-CMV IgG) (rs = 0.383, p = 0.040), as well as between the antibodies titers to the nuclear antigen of Epstein-Barr virus (anti-EBV NA IgG) and antibodies to core antigen of Epstein-Barr (anti-EBV VCA IgG) (rs = 0.584, p = 0.002) in patients with persistent mixed infection of these herpesviruses.

Annually in Ukraine, about 17 thousands of newborns are at risk of vertical infection with hepatitis B and C. Identification of infected women at the stage of family planning is the best way to prevent infection in newborns, and therefore it must be performed strictly in accordance with established norms. In case of detection of hepatitis, further tactics depend on the variant of the virus: in case of hepatitis C, pre-pregnancy treatment is preferable. In case of hepatitis B — pregnancy with subsequent simultaneous vaccination of the newborn. Antiviral therapy is possible in women with high viral load to prevent intrauterine infection. Similar tactics should be followed in case of in vitro fertilisation too. The text of the lecture is illustrated by clinical examples. The lecture is intended for infectious disease physicians and obstetrician-gynecologists.

The relevance of screening is discussed in the review in indissoluble connection with World Health Organization position on the need to eliminate hepatitis С viral infection by 2030 in Europe and the US. It was quoted the definition of screening and the criteria that make screening appropriate. The indications for screening, given in the National Guidelines, and the need for their clarification in accordance with the epidemiological situation in Ukraine are discussed. Based on an analysis of 55 literature sources, the authors conclude that screening is an important tool that opens a way to antiviral treatment for the patients with hepatitis. Screening should be properly organized, because otherwise it will be inefficient or extremely expensive. Generally accepted criteria for the screening should be adapted to the epidemiological situation in the region, taking into account the prevailing routs of transmission. Patients can be recruited for screening through the media, but the most effective is selection that conducted by health professionals. It is necessary to constantly adapt the criteria for selecting patients for screening in accordance with the changing epidemiological situation over time.

In the article results of own researches concerning peculiarities of the course of asthenic syndrome in school-aged children with chronic hepatitis B, C and mixed forms are provided. It is established that chronic hepatitis C as well as a mixed hepatitis are accompanied by more evident symptoms of deadaptation and somatogenic asthenia than hepatitis B in which psychogenic manifestations prevailed. The degree of endogenous intoxication was also higher at hepatitis C.

Background The breast is affected by a variety of benign disorders with a wide range of imaging and histopathological characteristics. Epidemiological investigations indicate that more than 50% of women will have one of the benign breast disorders beyond the age of 20 years. Objectives The objective of this study is to evaluate females with benign breast disorders attending the breast clinic in Duhok city by the triple assessment method. Patients and methods This is a prospective study conducted in Duhok Breast Clinic at Azadi Teaching Hospital from May 2017 to July 2018 which included 445 female patients with benign breast diseases. The patients were assessed by the triple assessment method (clinical examination, imaging and histopathological evaluation), females from all age groups were included. Patients with malignant disease and male patients were excluded from the study. Results The mean age of the patients was 34.65 years; breast pain was reported in 403 patients 73 patients presented with breast lump or lumps, 42 patients presented with nipple discharge, 36 patients were presented with nipple retraction. From these the total number of the patients 55 of them were reassured and no further work up was done, 235 sent for ultrasound examination,36 sent for mammography, 22 sent for both ultrasound and mammography and 4 patients were sent for MRI of the breast. Excisional biopsy done for 37 patients, FNAC in 28 patients, tru cut biopsy in 10 patients and cytological examination for the fluid discharge in 18 patients. Mastalgia was the commonest disorder seen in 376 patients, Ductectasia in 60 cases, Fibrocystic disease in 36cases, fibroadenoma in 33cases, breast cysts in 28 cases. Conclusions Benign breast diseases is a common problem in women, in this study mastalgia is the commonest followed by benign and inflammatory lesions. The use of the triple assessment to approach breast pathologies increase the diagnostic yield. Surgeons evaluating breast pain should have more rational criteria in using further sophisticated, expensive and invasive tests.

Introduction Fistula Laser Closure (FiLAC) is a method that was originally applied in the treatment of perianal fistulas. Because of promising results, diode lasers were later on used to treat pilonidal sinus disease in a method called sinus Laser Closure (SiLaC). The aim of this study is to compare between SiLaC and Limberg flap in management of pilonidal disease. Methods A prospective, nonrandomized comparative study. A short-term follow-up of 71 patients with pilonidal disease was analyzed (24 operated on using the SiLaC technique and 47 using the Limberg technique). With a primary outcome is healing rate and recurrence and a secondary outcome is other measures i.e. complications, hospital stay and postoperative pain. Results The median operative time in the SiLaC group was 26.45 ± 5.41 min (20–35 min) and in the Limberg group 58.63 ± 7.42 min (50–75 min). In the SiLaC group, the primary healing was achieved in 23 out of 24 patients (95.8%) with a total complication rate of 20.83%. There were two cases of recurrence after initial healing in each group. Conclusion Sinus laser Closure (SiLaC) is comparable to Limberg flap technique in the terms of healing rate and recurrence with better outcome regarding operative time, hospital stay and post-operative pain.

The presence of digestive symptoms associated with irritable bowel syndrome (IBS) in patients with inflammatory bowel disease (IBD) in remission is a topic of growing interest. Although there is heterogeneity in clinical studies regarding the use of IBD remission criteria and the diagnosis of IBS, the available data indicate that the IBD-IBS overlap would affect up to one third of patients in remission, and they agree on the finding of a negative impact on the mental health and quality of life of the individuals who suffer from it. The pathophysiological bases that would explain this potential overlap are not completely elucidated; however, an alteration in the gut-brain axis associated with an increase in intestinal permeability, neuroimmune activation and dysbiosis would be common to both conditions. The hypothesis of a new clinical entity or syndrome of "Irritable Inflammatory Bowel Disease" or "Post-inflammatory IBS" is the subject of intense investigation. The clinical approach is based on certifying the remission of IBD activity and ruling out other non-inflammatory causes of potentially treatable persistent functional digestive symptoms. In the case of symptoms associated with IBS and in the absence of sufficient evidence, comprehensive and personalized management of the clinical picture (dietary, pharmacological and psychotherapeutic measures) should be carried out, similar to a genuine IBS.

Background/Purpose The application of the checkbox for identifying patients with traits of both chronic obstructive pulmonary disease (COPD) and asthma proposed by the 2015 Global Initiative for Asthma (GINA)/Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations has not been well studied although such identification is important in clinical practice. Thus, we aimed to investigate the prevalence and features of COPD coexistent with asthma traits diagnosed based on the 2015 GINA/GOLD strategies, and explore the gap between guidelines and routine practice in the diagnosis and pharmacological management of such condition in a COPD cohort. Methods COPD subjects were enrolled retrospectively throughout Taiwan. A patient record form was completed for each participant and the data were analyzed. Results Of 340 participants, the prevalence of COPD coexistent with traits of asthma was 39.4% and 30.3% based on guidelines and physician's judgment, respectively. Coexistent patients were characterized by blood eosinophilia, higher total immunoglobulin E (IgE) levels, preserved lung function, and the presence of gastro-esophageal reflux disease and atopic disease while total IgE level > 100 kU/L and the presence of atopic disease were predictors for coexistent patients. Gaps existed in the diagnosis (a weak agreement with kappa = 0.53) and treatment (non-adherence to the preferred therapy in 18.4% of physician-judged coexistent patients) in COPD patients with asthma traits. The exacerbation history was similar between coexistent and non-coexistent patients. Conclusion We found that measuring circulatory eosinophil and total IgE levels may raise clinicians’ awareness of the presence of traits of asthma in the management of COPD.

Objective: To determine long-term outcomes of a randomized trial (BIOPEX) comparing biological mesh and primary perineal closure in rectal cancer patients after extralevator abdominoperineal resection and preoperative radiotherapy, with a primary focus on symptomatic perineal hernia. Summary Background Data: BIOPEX is the only randomized trial in this field, which was negative on its primary endpoint (30-day wound healing). Methods: This was a posthoc secondary analysis of patients randomized in the BIOPEX trial to either biological mesh closure (n = 50; 2 dropouts) or primary perineal closure (n = 54; 1 dropout). Patients were followed for 5 years. Actuarial 5-year probabilities were determined by the Kaplan-Meier statistic. Results: Actuarial 5-year symptomatic perineal hernia rates were 7% (95% CI, 0-30) after biological mesh closure versus 30% (95% CI, 10-49) after primary closure (P = 0.006). One patient (2%) in the biomesh group underwent elective perineal hernia repair, compared to 7 patients (13%) in the primary closure group (P = 0.062). Reoperations for small bowel obstruction were necessary in 1/48 patients (2%) and 5/53 patients (9%), respectively (P = 0.208). No significant differences were found for chronic perineal wound problems, locoregional recurrence, overall survival, and main domains of quality of life and functional outcome. Conclusions: Symptomatic perineal hernia rate at 5-year follow-up after abdominoperineal resection for rectal cancer was significantly lower after biological mesh closure. Biological mesh closure did not improve quality of life or functional outcomes.

Contains fulltext : 251531.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To quantify the impact of individual complications on mortality, organ failure, hospital stay, and readmission after pancreatoduodenectomy. SUMMARY OF BACKGROUND DATA: An initial complication may provoke a sequence of adverse events potentially leading to mortality after pancreatoduodenectomy. This study was conducted to aid prioritization of quality improvement initiatives. METHODS: Data from consecutive patients undergoing pancreatoduodenectomy (2014-2017) were extracted from the Dutch Pancreatic Cancer Audit. Population attributable fractions (PAF) were calculated for the association of each complication (ie, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, delayed gastric emptying, wound infection, and pneumonia) with each unfavorable outcome [ie, in-hospital mortality, organ failure, prolonged hospital stay (>75th percentile), and unplanned readmission), whereas adjusting for confounders and other complications. The PAF represents the proportion of an outcome that could be prevented if a complication would be eliminated completely. RESULTS: Overall, 2620 patients were analyzed. In-hospital mortality occurred in 95 patients (3.6%), organ failure in 198 patients (7.6%), and readmission in 427 patients (16.2%). Postoperative pancreatic fistula and postpancreatectomy hemorrhage had the greatest independent impact on mortality [PAF 25.7% (95% CI 13.4-37.9) and 32.8% (21.9-43.8), respectively] and organ failure [PAF 21.8% (95% CI 12.9-30.6) and 22.1% (15.0-29.1), respectively]. Delayed gastric emptying had the greatest independent impact on prolonged hospital stay [PAF 27.6% (95% CI 23.5-31.8)]. The impact of individual complications on unplanned readmission was smaller than 11%. CONCLUSION: Interventions focusing on postoperative pancreatic fistula and postpancreatectomy hemorrhage may have the greatest impact on in-hospital mortality and organ failure. To prevent prolonged hospital stay, initiatives should in addition focus on delayed gastric emptying.

Steatohepatitis and diarrhea are well-known complications in children undergoing liver transplantation (LT) for progressive familial intrahepatic cholestasis (PFIC) type 1. Despite medical management with bile acid binders, the condition is progressive and can be associated with allograft loss. We report the case of a seven-year-old boy who underwent LT at the age of 2 years for PFIC type 1. Over the next five years, he developed refractory diarrhea, emaciation, worsening liver function, and steatohepatitis. Aiming to interrupt the enterohepatic circulation, at the age of 7 years, he underwent a total internal biliary diversion. The patient's postprocedure period was uneventful. His diarrhea settled and the transaminases normalized his follow-up liver biopsy after a year showed a complete resolution of steatohepatitis. At 18 months' follow-up, he has gained weight and remains asymptomatic. In this report, we show post-LT complications especially allograft injury related to the pathology of PFIC-1 can be safely and effectively managed by performing a total internal biliary diversion.

Background: Ventilation limitation has a significant adverse effects on cardiovascular function and tissue oxygenation during exercise in patients with chronic obstructive pulmonary disease (COPD). High flow nasal cannula (HFNC) improve ventilation by washing out the anatomical dead space and providing oxygen at constant concentration. This study aimed to examine the effects of HFNC on the exercise performance and hemodynamic status in COPD patients. Methods: Fifteen patients with COPD performed two constant load exercise tests (CLET) at the 70% of maximum workload achieved at a previous incremental exercise test on arm ergometer. The CLET were performed with HFNC and with nasal cannula (NC) in random order. The hemodynamics parameters of subjects during exercises were measured by a bioelectrical impedance device. The tissue oxygenation status (oxygenated hemoglobin, deoxygenated hemoglobin (hHb), total hemoglobin) was measured by a near infrared spectrophotometer. Results: The exercise duration was longer for HFNC test than NC test (962.9 ± 281.7 s, vs 823.9 ± 184.9 s, p < 0.05). At the end of CLET, the PetCO2 was lower for HFNC than NC (29.3 ± 5.1 mmHg vs 32.1 ± 5.5 mmHg, p 0.05), stroke volume (NC:73.5 ± 21.0 vs HFNC 67.5 ± 16.3 ml, p > 0.05). The changes of hHb in muscle tissues was significantly lower in HFNC test than that in NC test (p

Background Cancer-associated venous thromboembolism (VTE) is a distinct pathological entity with much higher incidence and unique risk factors compared to general VTE. A previous study reported that cancer associated-VTE incidence in Taiwan is much lower than that reported for western countries and also lower than our anecdotal observations. To address this issue further, we initiated an investigation locally using a more detailed approach than used previously with comprehensive review of medical records to gain new insight into the incidence and risk factors for cancer-associated VTE. Methods Medical records of all adult patients with lung, pancreatic and gastric cancers, and lymphoma diagnosed from January 2011 to December 2013 in National Taiwan University Hospital indexed through the local cancer registry database were reviewed. VTE patients were identified through diagnosis coding and comprehensive medical chart review. Results Among 5620 consecutive lung, gastric and pancreatic cancer, and lymphoma patients, VTE was diagnosed in 246 (4.4%). Overall VTE incidence was 36.3 per 1000 patient-year. Multivariate analysis showed that not only high but also low body mass index (BMI) was associated with VTE risk with different cutoff levels by gender. Mildly to moderately anemic patients were at higher risk of VTE. Activated partial thromboplastin time (aPTT) had proportionally and reversely correlation to VTE risk. Conclusion We reported higher incidence of cancer associated VTE in Taiwan. Low BMI and short aPTT were found to be related to higher VTE risk that was not reported before.

Background/Purpose: Sphingolipids are major constituents of eukaryotic cell membranes and play key roles in cellular regulatory processes. Our recent results in an experimental stroke animal model demonstrated changes in sphingolipids in response to acute ischemic brain injury. This study aimed to investigate the plasma levels of sphingosine-1-phosphate (S1P) and ceramides in acute ischemic stroke (AIS) patients and their associations with functional outcomes. Methods: Plasma samples were collected from patients with AIS at