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Background/Aims: The study aimed to evaluate the effectiveness and safety of self-expanding metal stents (SEMS) in the management of post-surgical esophageal leaks. Methods: Retrospective data of consecutive patients with a post-surgical esophageal leak treated by means of a metal stent between January 2008 and December 2014 at the Humanitas Research Hospital (Milan, Italy) were extracted from a prospectively maintained register of SEMS used for benign indications, such as post-surgical benign esophageal strictures and/or leaks. The primary outcome of the study was to assess the rate of successful leak closure and to identify the variables associated with its achievement. As a secondary outcome, we evaluated the overall safety of SEMS placement and the efficacy and safety for different types of SEMS in this specific setting of patients. Leak resolution was documented with endoscopic and/or imaging studies. In the case of leak persistence, further attempts of esophageal stenting were carried out at the discretion of both endoscopists and surgeons. Results: A total of 49 patients were included in the study (men 41 of 49, 83.7%, mean age 62.4 ± 11.9). One patient was excluded from analysis, because of death 1 day after stent insertion due to worsening of pre-existing mediastinitis. A total number of 82 stents were placed (mean number of stents per patient: 1.7) in 49 patients: 35 patients (71.4%) received a partially covered SEMS (PCSEMS) as the first stent positioned, while the remaining 14 (28.6%) received a fully covered SEMS (FCSEMS); but 1 patient (2%) died following stent insertion; therefore, data regarding therapeutic success were available for 48 patients. Stents were left in place for a mean period of 21.9 ± 15.2 days. Leak closure after the first stent placement was achieved in 22 of 48 (45.8%) patients. Of the 26 patients with failure of index stent placement, 18 patients underwent further stenting attempts (69.2%), and secondary closure of leak was achieved in 7 (38.9%) of these 18 patients. Thus, the overall success rate was 60.5% (29 of 48). On the basis of stent type, the success rate was 57.1% (8 of 14) for FCSEMS and 64.7% (22 of 34) for PCSEMS. Logistic regression analysis did not find any significant association between successful leak closure and analyzed variables. Overall mortality was 13.0%. Complication rate was 38.8% (19 of 49 patients). Conclusion: The use of SEMS is an effective and safe option for post-surgical esophageal leaks, with no evidence of any significant influence of stent type on outcome.

Benign colorectal strictures (BCRS) represent a challenging clinical scenario and are difficult to manage. They mostly originate from postoperative anastomotic strictures, diverticular disease, or Crohn׳s disease. Surgery has traditionally been the mainstay of treatment but is associated with high complication rates and morbidity. Nonsurgical strategies for managing BCRS include endoscopic dilation, incision with electrocautery, microwave coagulation therapy, laser therapy, and local steroid injection. These modalities are often associated with high complication and recurrence rates. Stent therapy is an alternative nonsurgical option. It has demonstrated good results in the setting of malignancy, both as bridge to surgery and as palliative treatment. Stents have been used in the benign setting with the same indications. However, evidence in this regard is very scarce and inconclusive, and therefore this option is still controversial. There is still uncertainty in indications to stent in BCRS, as well as in timing of both stent placement and removal. The most commonly employed stents have been self-expanding metal stents; experience with plastic and biodegradable stents is less common. The overall efficacy for relief of obstruction in the benign setting seems to be lower than in the setting of malignancy. It seems to be effective in the short and medium terms, but stricture recurrence is quite common, occurring in nearly half of the patients. The few available data with biodegradable stents suggest that they may become an important treatment option in the future. Stenting in the benign setting has been associated with significant morbidity and complications, more so than in the malignant setting. Uncovered stents for example are currently contraindicated for the treatment of BCRS, unless they are used as bridge to surgery. Stenosis arising from inflammation, such as observed in acute diverticulitis and Crohn׳s disease, as well as radiation-induced strictures may be more prone to complications, thus more caution is recommended while considering stenting in this setting. Future studies should be aimed at defining the best subpopulation of patients that would benefit from stent placement, and new stents should be designed to increase long-term patency rates and reduce complications. In this article, we review the state of art of stenting in the benign setting and point toward future avenues in the management of this challenging clinical scenario.

Benign esophageal strictures are a common problem in endoscopic practice. The predominant symptom of patients is dysphagia. The initial treatment option for a benign esophageal stricture is dilation. A small subgroup of strictures, that is, those that are long (>2 cm), are tortuous, and have a narrow diameter, or are associated with caustic or postradiotherapy etiology, tend to recur and are therefore called refractory. Temporary stent placement, with either a self-expandable metal stent or a self-expandable plastic stent, can be considered as a treatment option in these patients. From a technical point of view, placement of an expandable stent in benign strictures does not differ from placement in cases of palliation of malignant dysphagia. Deep sedation and careful stent placement, especially in proximal locations, is extremely important. Results of temporary stenting are still inconclusive; long-term clinical resolution of the stricture is achieved in less than 50% of patients. Moreover long-term data on safety and efficacy are scant. These disappointing results are mainly because of hyperplastic tissue ingrowth or overgrowth and stent migration. New stent designs are needed for this indication. Promising initial results show that biodegradable stents may be useful for refractory benign esophageal strictures; however, these preliminary data need to be further elucidated in future studies.

PURPOSE: This study was undertaken to compare response evaluation criteria in solid tumours (RECIST) 1.1 and modified RECIST (mRECIST) in patients with unresectable hepatocellular carcinoma (HCC) on sorafenib, and to describe HCC enhancement changes before and after sorafenib treatment. METHODS AND MATERIALS: Seventeen patients (12 men, 5 women; mean age 69 years; age range 58-79 years) were included. Tumour response was assessed according to RECIST and mRECIST. Two readers placed a region of interest (ROI) within each target lesion, on the portion showing enhancement during the arterial phase. The lesion attenuation values measured within the ROIs on computed tomography or the signal intensity measured on magnetic resonance imaging, during the unenhanced phase, hepatic arterial phase and venous phase were recorded. Changes in arterial and venous contrast enhancement before and after treatment were compared among the mRECIST groups using Mann-Whitney U test. RESULTS: Agreement between mRECIST and RECIST was good (Cohen's k coefficient, 0.791). Patients with partial response had a greater decrease in arterial enhancement (-79.8%) than did patients with stable disease (SD) (-24.8%; p = 0.011) or progressive disease (PD) (-32.9%; p = 0.034). No statistically significant difference in arterial enhancement variation was found among patients with SD and PD. No statistically significant difference in venous enhancement was found among the mRECIST groups. CONCLUSIONS: mRECIST showed a more favourable response compared to RECIST 1.1 in patients with unresectable HCC receiving sorafenib.

Hepatocellular carcinoma (HCC) has a high incidence all over the world. Even if the primary end point of treatment of HCC is survival, radiological response could be a surrogate end point of survival, and could have a key role in clinical management. Since 1950 several radiological response criteria have been applied; however, it was not until 2000 that specific criteria for HCC were introduced by the European Association for the Study of the Liver (EASL), and these were then standardized in 2010 with the development of the modified Response Evaluation Criteria for Solid Tumors (mRECIST) for HCC. The purpose of this brief review is to compare data in literature regarding the application and the performance of mRECIST in clinical practice, and to discuss unclear and open issues.

Hepatocellular carcinoma is a major health problem. It is the sixth most common cancer worldwide and the third most common cause of cancer-related death. Despite the availability of several treatment opportunities, diagnosis is still made in an advanced phase, limiting application of most therapeutic choices that currently are based on the Barcelona Clinic Cancer Liver Classification and include surgical resection, orthotopic liver transplantation and ablative methods for very early and early disease, arterial chemoembolization for intermediate stages and systemic therapy with sorafenib for advanced hepatocellular carcinoma. Thanks to novel advancements in knowledge of molecular pathogenesis of this tumor, many new systemic agents and locoregional treatments are in different stages of clinical development and they represent an important promise of further improvements in patients' survival.

Aliment Pharmacol Ther 2011; 34: 196–204 Summary Background Transarterial chemoembolisation (TACE) is first-line treatment in unresectable hepatocellular carcinoma (HCC) and rescue treatment after failure of radical treatments in early stage HCC. Prognostic tools for HCC using time-fixed Cox models may be unreliable in patients treated with TACE because time-varying predictors interact. Aim To explore time-dependent variables as survival predictors in patients with HCC receiving TACE as first-line or second-line treatment. Methods Eighty four consecutive patients with HCC (mean age 68; male gender 62%; Child-Pugh class: A n = 73, B n = 11; Barcelona Clinic Liver Cancer class: A n = 44, B n = 24, C n = 16) treated with TACE were enrolled. Clinical, laboratory and radiological follow-up data were collected from the time of first treatment. Time-fixed and time-dependent Cox analyses were done. Results Overall survival rates were 89.6% (95% CI 82.5–97.2) at 12 months, 58.8% (95% CI 46.2–74.9) at 24, 35.4% (95% CI 22.3–56.1) at 36 and 17.2% (95% CI 7.0–41.7) at 48 months. Performance status (P

Non Hodgkin lymphoma frequently involves the gastrointestinal tract, in particular the stomach and the small bowel. Rarely, it can also be a cause of pancreatic masses. Clinical presentation is often non-specific and may overlap with other pancreatic conditions such as carcinoma, neuroendocrine tumours and autoimmune pancreatitis. We report a case of primary pancreatic lymphoma in a young woman with jaundice, fever and abdominal pain mimicking autoimmune pancreatitis. Clinical evaluation included the abdominal Computed Tomography scan, Magnetic Resonance Imaging and an upper gastrointestinal endoscopy that revealed a large duodenal mass. Endoscopic biopsies were performed and eventually histological examination was coherent with a diagnosis of primary pancreatic lymphoma.

Hepatocellular carcinoma (HCC) is a challenging malignancy of global importance. It is associated with a high rate of mortality and its prevalence in the United States and in Western Europe is increasing. Cirrhosis is the strongest and the most common known risk factor for HCC, usually due to hepatitis C virus (HCV) and hepatitis B virus (HBV) infections. However, different lines of evidence identify in non-alcoholic fatty liver disease (NAFLD) a possible relevant risk factor for occurrence of HCC. Given the continuing increase in the prevalence of obesity and diabetes, the incidence of non-alcoholic steatohepatitis-related HCC may also be expected to increase, and a potential role of behavior treatment and/or insulin-sensitizing drugs can be envisaged. Vaccination against HBV is the most efficient primary prevention measure currently available to reduce the HCC incidence and mortality in high-incidence areas, while data on the role of interferon (IFN) and nucleos(t)ide analogues (NUC) are still controversial. The pooling of data from the literature suggests a slight preventive effect of antiviral therapy on HCC development in patients with HCV-related cirrhosis, but the preventive effect is limited to sustained virological responders.

Hepatocellular carcinoma (HCC) is a major health problem. It is currently the third cause of cancer-related death, it is highly prevalent in the Asia–Pacific region and Africa, and is increasing in Western countries. The natural history of HCC is very heterogeneous and prediction of survival in individual patients is not satisfactory because of the wide spectrum of the disease. During the past decade, major advances have been achieved in prevention, through better surveillance of patients at risk, and in therapy through better surgical and ablative therapies and multimodal treatment approaches. Moreover, the increasing knowledge of molecular hepatocarcinogenesis provides the opportunity for targeted therapies. In this setting, the impact of sorafenib on advanced-stage HCC is a landmark finding in the treatment of liver cancer. The role of sorafenib administration as adjuvant therapy after curative treatment is being evaluated in clinical studies. Future research should lead to a molecular classification of the disease and a more personalized treatment approach.