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Background Percutaneous endoscopic gastrostomy (PEG) is the most common endoscopic procedure used to provide nutritional support. Aim To prospectively evaluate the mortality and complication incidences after PEG insertion or replacement. Methods All patients who underwent PEG insertion or replacement were included. Details on patient characteristics, ongoing therapies, comorbidities, and indication for PEG placement/replacement were collected, along with informed consent form signatures. Early and late (30-day) complications and mortality were assessed. Results 950 patients (47.1% male) were enrolled in 25 centers in Lombardy, a region of Northern Italy. Patient mean age was 73 years. 69.5% of patients had ASA status 3 or 4. First PEG placement was performed in 594 patients. Complication and mortality incidences were 4.8% and 5.2%, respectively. The most frequent complication was infection (50%), followed by bleeding (32.1%), tube dislodgment (14.3%), and buried bumper syndrome (3.6%). At multivariable analysis, age (OR 1.08 per 1-year increase, 95% CI, 1.0–1.16, p = 0.010) and BMI (OR 0.86 per 1-point increase, 95% CI, 0.77−0.96, p = 0.014) were factors associated with mortality. PEG replacement was carried out in 356 patients. Thirty-day mortality was 1.8%, while complications occurred in 1.7% of patients. Conclusions Our data confirm that PEG placement is a safe procedure. Mortality was not related to the procedure itself, confirming that careful patient selection is warranted.

AIMS This multicentre cohort study evaluated the role of ageing on clinical characteristics, treatment allocation and outcome of new hepatocellular carcinomas (HCCs), in clinical practice. MATERIAL & METHODS From September 2008, 541 patients >70 years old (elderly group), and 527 ≤70 years old (non-elderly group) with newly diagnosed HCC were consecutively enrolled in 30 Italian centres. Differences in clinical characteristics and treatment allocation between groups were described by a multivariable logistic regression model measuring the inverse probability weight to meet the elderly group. Survival differences were measured by unadjusted and adjusted (by inverse probability weight) survival analysis. RESULTS Elderly patients were mainly females, hepatitis C virus infected and with better conserved liver function (P

Recent data suggest that outcome of hepatocarcinoma is improving. In order to explore whether survival is also increasing in clinical practice, we compared two multicenter independent in-field cohorts of cirrhotics with newly diagnosed HCCs. Cohort 1 (C1) consisted of 327 patients enrolled between January and December 1998, and cohort 2 (C2) included 826 patients enrolled between September 2008 and November 2012. Patients were stratified according to Child-Pugh score, MELD score, and HCC staged according to TNM, BCLC systems. At baseline, C2 patients were significantly older, with more frequent comorbidities and better liver function. In C2, HCC was more frequently detected under regular ultrasound surveillance (P

Background: Open-access endoscopy allows physicians to directly schedule endoscopic procedures for their patients without prior consultation. Evaluation of both appropriateness and diagnostic yield of endoscopic procedures is critical when assessing the costs and benefits of endoscopy in an open-access setting. The aim of this study was to assess the appropriate use of colonoscopy in an open-access system and to establish the yield of diagnostic information relevant to patient care. Methods: Overall, 1123 consecutive patients referred for open-access colonoscopy were prospectively enrolled in the study. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relationship between the appropriate use of colonoscopy and the presence of relevant endoscopic findings. Results: The rate of colonoscopies “generally not indicated” according to ASGE guidelines was 29% (39% for primary care physicians and 23% for specialists; p < 0.0001). A relevant endoscopic finding was detected in 338 examinations (35%). The diagnostic yield was significantly higher for “generally indicated” colonoscopies (43%) compared with “generally not indicated” procedures (16%) (p < 0.001). Conclusions: Although the rate of inappropriate use of colonoscopy was high, open-access colonoscopy was effective in detecting neoplastic lesions. Because most of these were detected during examinations performed for appropriate indications, the appropriateness of the indication emerges as crucial to the cost-effectiveness of an open-access system. (Gastrointest Endosc 2001;54:175-9.)

We report a case of transient acute gastroduodenal dilation complicated by perforation after BoNT injection for treatment of achalasia. An 81-year-old woman with a 3-year history of achalasia was evaluatedfortherecurrenceofdysphagiaforbothsolids and liquids, without ever reporting abdominal distention or changes in bowel habits. Her medical history was unremarkable except for hip replacement surgery. At achalasia diagnosis, she refused both pneumatic dilation and surgery because of potential risks and underwent BoNT injection. Treatment was successful, and the patient had beendoingwellfor3years.Becauseofthelong-lastingremission of symptoms and the patient’s age, repetition of BoNT treatment was proposed. Upper endoscopy was performed with the patient under conscious sedation; a total dose of 100unitsofBoNTtypeA(Botox;Allergan,Irvine,Calif),individed25-U/mLaliquotsintothe4quadrants1cmabovetheZline, was injected by using a standard sclerotherapy needle. 6 Three days later, the patient presented because of abdominal distention and pain. An upright plain abdominal radiograph showed massive gastric distention with an airfluidlevelintheleftupperabdominalquadrant.Athoracoabdominal contrast CTscan confirmed the huge distention of the stomach, bulb, and second portion of the duodenum andalsoruledoutthepresenceofbowelobstruction(Fig.1). Anattempttopositionadecompressivenasogastrictube failed, and urgent upper endoscopy was then performed, which allowed aspiration of approximately 6 L of fluid and coffee-ground material and immediate resolution of the abdominal distention. Multiple petechiae and large darkish erosions were observed inthe fundus and along the greater curvature. A nasogastric tube was positioned in the gastric cavity and was left in place for 5 days. Subsequent serial abdominal plain films obtained during the hospital stay showed neither the recurrence of gastroduodenal distention nor the occurrence of ileocolonic distention. The clinical course was complicated by severe sepsis related to subdiaphragmaticabscessescausedbyagastricmicroperforation, which were successfully managed conservatively with percutaneous drainage and broad-spectrum antibiotics. The patient was discharged 6 weeks after admission

Background: Based on ASGE guidelines or complex derived criteria, mainly related to specific clinically scenarios, up to 30% of lower GI tract endoscopy (LE) are inappropriate in an open-access system. Aims: To assess a)the inappropriate rate of LE required by general practitioners (GPs) or specialists, and b)the clinical indications and diagnostic yield of inappropriate vs appropriate LE. Methods: From June to December 1998, consecutive patients referred for LE were prospectively studied. Before endoscopy, a questionnaire was filled to assess the appropriateness of the request in the 8 scheduled clinical situations in which ASGE-guidelines were reduced: screening, follow-up, long-lasting (>3 months) or recentonset symptoms or signs in patients never or already studied, operative endoscopy and to complete a previous colonic study (endoscopy or barium enema). Results: Out of 1045 LE, 154/393(40%) sent by GPs and 150/652 (23%)sent by specialists were judged inappropriate (p