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In 2011 the three major Italian gastroenterological scientific societies (AIGO, the Italian Society of Hospital Gastroenterologists and Endoscopists; SIED, the Italian Society of Endoscopy; SIGE, the Italian Society of Gastroenterology) prepared their official document aimed at analysing medical care for digestive diseases in Italy, on the basis of national and regional data (Health Ministry and Lombardia, Veneto, Emilia-Romagna databases) and to make proposals for planning of care. Digestive diseases were the first or second cause of hospitalizations in Italy in 1999–2009, with more than 1,500,000 admissions/year; however only 5–9% of these admissions was in specialized Gastroenterology units. Reported data show a better outcome in Gastroenterology Units than in non-specialized units: shorter average length of stay, in particular for admissions with ICD-9-CM codes proxying for emergency conditions (6.7 days versus 8.4 days); better case mix (higher average diagnosis-related groups weight in Gastroenterology Units: 1 vs 0.97 in Internal Medicine units and 0.76 in Surgery units); lower inappropriateness of admissions (16–25% versus 29–87%); lower in-hospital mortality in urgent admissions (2.2% versus 5.1%); for patients with urgent admissions due to gastrointestinnal haemorrhage, in-hospital mortality was 2.3% in Gastroenterology units versus 4.0% in others. The present document summarizes the scientific societies’ official report, which constitutes the “White paper of Italian Gastroenterology”

none 33 no This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms open Italian Association of Hospital Gastroenterologists and Endoscopists; Italian Association for the Study of the Pancreas; Buscarini E; Pezzilli R; Cannizzaro R; De Angelis C; Gion M; Morana G; Zamboni G; Arcidiacono P; Balzano G; Barresi L; Basso D; Bocus P; Calculli L; Capurso G; Canzonieri V; Casadei R; Crippa S; D'Onofrio M; Frulloni L; Fusaroli P; Manfredi G; Pacchioni D; Pasquali C; Rocca R; Ventrucci M; Venturini S; Villanacci V; Zerbi A; Falconi M; Cystic Pancreatic Neoplasm Study Group Italian Association of Hospital Gastroenterologists and Endoscopists; Italian Association for the Study of the Pancreas; Buscarini E; Pezzilli R; Cannizzaro R; De Angelis C; Gion M; Morana G; Zamboni G; Arcidiacono P; Balzano G; Barresi L; Basso D; Bocus P; Calculli L; Capurso G; Canzonieri V; Casadei R; Crippa S; D'Onofrio M; Frulloni L; Fusaroli P; Manfredi G; Pacchioni D; Pasquali C; Rocca R; Ventrucci M; Venturini S; Villanacci V; Zerbi A; Falconi M; Cystic Pancreatic Neoplasm Study Group

The SOCEUS survey aims to evaluate how contrast-enhanced ultrasound (CEUS) is effectively used in the focal liver lesions characterization.In the survey were involved Verona, Brescia and Trieste Radiological Centers and Arezzo and Bologna Non-radiological Centers. Inclusion criteria were liver focal lesion detection at conventional ultrasound and studied by means of CEUS, with or without CT or MRI examinations, done previous or subsequent to CEUS.1069 forms were collected. Patients with benign lesions, who did not undergo any other studies, were 255/561 (45.5 %). Among patients with diagnosis of hemangioma at CEUS, those who had no other investigations were 129/267 (48.3 %). Patients with malignant lesions who had studies pre-CEUS (CT and/or MRI) were 328/508 (65 %), whereas those who had examinations post-CEUS (CT and/or MRI) were 218/508 (42.9 %). Concordance rate between CEUS and CT investigations pre- and post-CEUS was, respectively, 66 and 89 %. Concordance rate between CEUS and MRI studies pre- and post-CEUS was, respectively, 87.5 and 81.5 %.This study proves contrast-enhanced ultrasound correct application in the involved centers.Il sondaggio SOCEUS ha lo scopo di valutare come l’ecografia con mezzo di contrasto sia effettivamente impiegata nella caratterizzazione delle lesioni focali epatiche.Nel sondaggio sono tati coinvolti i centri radiologici di Verona, Brescia e Trieste e i centri non radiologici di Arezzo e Bologna. I criteri di inclusione sono stati la presenza di lesione focale epatica all’esame ecografico convenzionale studiata con ecografia con mezzo di contrasto, con o senza correlazione TC or RM, prima o dopo l’esame ecografico.Sono state raccolte 1069 schede. I pazienti con lesioni benigne che non hanno fatto altri esami sono stati 255/561 (45.5 %). Dei pazienti con diagnosi di angioma alla ecografia con mezzo di contrasto, quelli che non hanno eseguito altre indagini sono stati 129/267 (48.3 %). I pazienti con lesioni maligne sottoposti ad indagini pre-ecografia con mezzo di contrasto (TC e/o RM) sono stati 328/508 (65 %), mentre quelli che hanno eseguito esami post- ecografia con mezzo di contrasto (TC e/o RM) sono stati 218/508 (42.9 %). La concordanza tra ecografia con mezzo di contrasto ed esame TC pre- e post-ecografia con mezzo di contrasto sono rispettivamente state pari al 66 e 89 %. La concordanza tra l’ecografia con mezzo di contrasto e l’esame RM pre- e post-ecografia con mezzo di contrasto sono state rispettivamente di 87.5 e 81.5 %.Lo studio prova che l’ecografia con mezzo di contrasto è utilizzata correttamente nei Centri valutati.

Purpose The typical appearance of focal nodular hyperplasia (FNH) in radiological contrast techniques (helical CT or MRI) includes homogeneous enhancement in the arterial phase, but the exact timing for the best visualization of this pattern is unknown. The aim of the present study was to assess the ultrasound pattern of FNH with special attention to real-time contrast-enhanced ultrasonography (CEUS) appearance and specifically to the timing of perfusion patterns. Materials and methods 72 patients (60 females, 12 males) with a total of 90 FNH nodules with a diameter ranging from 8 to 100 mm (mean +/- SD, 40.6 +/- 21.5 mm) were examined continuously for at least 4 minutes using CnTI and CPS methods (ESAOTE, Genoa, Italy and Acuson-Siemens) after bolus injection of SonoVue (BRACCO, Milan, Italy). Results 87 of 90 nodules showed the typical coin-like hyperechogenicity in the arterial phase. The remaining three nodules were all in the same patient and were diagnosed as FNH after resection. Contrast started to appear within the lesions after a mean of 15.7 +/- 4.6 seconds (range 7 - 27 s) and reached peak signal intensity, with the greatest differentiation between the lesion and the surrounding parenchyma, at around 22.6 +/- 7.0 seconds (range 14 - 72 s). In the late phase, 65 lesions (72.2 %) became isoechoic (after a mean of 80.8 +/- 85.7 s, range 20 - 300 s), 22 (24.4 %) slightly hyperechoic and 3 (3.3 %) faintly hypoechoic. Conclusion FNH shows a typical homogeneous hyperechoic pattern during the arterial phase in real-time CEUS which disappears slowly on average but occasionally even as soon as 20 seconds after contrast injection. If the first scans are taken later than 20 seconds after injection (which is still considered to be a full arterial phase), the ultrasound hyperechogenicity may be missed in some cases. Real-time study of these lesions is therefore strongly recommended to avoid possible false-negative results.

To evaluate the safety, local effectiveness, and long-term results of laser thermal ablation (LTA) in the treatment of small hepatocellular carcinoma (HCC).Ninety-two biopsies proved small HCCs (range, 0.8-4.0 cm) in 74 patients who were treated percutaneously with LTA in an outpatient clinic. A laser at a power of 5.0 W was coupled with one to four fibers that were advanced through 21-gauge needle(s) for 6-12 minutes. All lesions were evaluated with computed tomography (CT) for changes in size and vascular pattern, recurrence rates, and cumulative survival rates. Patients were examined for complications.No major complications occurred in 117 LTA sessions, with an average of 1.3 sessions per tumor. At 3 months, CT scans showed a nonenhancing area (complete necrosis) in 89 (97%) of 92 lesions. During follow-up (range, 6-66 months; mean, 25.3 months), 84 tumors (91%) decreased in size. The local recurrence rates (range, 1-5 years) ranged from 1.6% to 6.0%. Recurrence rates (range, 12-60 months) in other liver segments ranged from 24% to 73%. Cancer-free survival rates (range, 1-4 years) ranged from 73% to 24%. Overall survival rates were 99%, 68%, and 15% at 1, 3, and 5 years, respectively. Twenty-one patients (28%) died.LTA is a safe and effective treatment for small HCC.

To determine the potential long-term effectiveness of laser thermal ablation (LTA) followed by transcatheter arterial chemoembolization (TACE) in the percutaneous ablation of large hepatocellular carcinoma (HCC).Thirty large HCCs 3.5-9.6 cm in diameter (mean diameter, 5.2 cm) and 15 small HCCs 0.8-3.0 cm (mean diameter, 1.9 cm) were treated with ultrasonographically guided LTA with TACE and with LTA alone, respectively, in 30 patients: 19 with a solitary large HCC, and 11 with one to three additional synchronous small HCCS: A 1.064-microm neodymium yttrium-aluminium-garnet (Nd-YAG) laser at a power of 5.0 W was coupled with one to four quartz optic fibers that were advanced through 21-gauge needles. Segmental TACE was performed 30-90 days after LTA. All lesions were evaluated for change in size at computed tomography (CT), alpha-fetoprotein (AFP) levels, recurrence rates, and cumulative survival rates.No major complications occurred in 127 LTA sessions. CT showed complete tumor necrosis in 27 (90%) of 30 large HCCS: Twenty-eight patients were followed up for 6-41 months (mean, 17.1 months). In 25 patients, all lesions appeared stable or smaller at CT. AFP levels decreased to the normal range in all patients with high pretreatment values. The 1-, 2-, and 3-year local recurrence rate was 7% in large HCCS: Complete tumor necrosis was achieved in all 15 (100%) small HCCs; none of them recurred locally. The 1-, 2-, and 3-year cumulative survival rates were 92%, 68%, and 40%, respectively.LTA followed by TACE is an effective palliative therapy in treating large HCCS

Percutaneous ethanol injection (PEI) has become a widely used procedure in the treatment of hepatocellular carcinoma (HCC). However, the criteria for selecting patients are not standardized, and little information is available about the complications of the procedure.A questionnaire was sent to 11 experienced Italian centers. It investigated: the size and the number of HCC nodules suitable for treatment and the Child-Pugh risk class of the associated cirrhosis; the performance of the procedure; the number and characteristics of the patients treated; and, finally, any complications.Most of the centers performed PEI in single HCC nodules less than 5 cm in diameter or in multiple nodules if fewer than three, the larger being less than 3 cm. Patients in Child-Pugh's classes A, B, and C with single nodules were generally considered for PEI. A prothrombin time of less than 40% and a platelet count of less than 40,000/mm3 contraindicated PEI in most of the centers. PEI was generally performed on outpatients, using Chiba or spinal needles. One thousand and sixty-six patients (8118 sessions) were enrolled; 74% had a single HCC nodule and 26% multiple nodules. All except four had cirrhosis; 53% were in Child class A, 38% in class B, and 9% in class C. The mean number of sessions needed to destroy an HCC nodule was 6.7 (range, 2-14), with a mean alcohol injection volume of 5.0 ml per session (range, 2-20 ml). One death (0.09%) and 34 complications (3.2%) were reported. Among the complications we call attention to the hemorrhagic ones (eight cases) and tumoral seeding (seven cases). Severe pain experienced during the maneuver led to discontinuation of the procedure in 3.7% of the patients; 13.5% of the patients required analgesics and 24% had fever after PEI.Some procedural aspects of PEI treatment differ among the various centers a standardization is advisable. In the present survey PEI is a low-risk technique.

Purpose Percutaneous laser ablation (PLA) has been proposed as an active treatment in patients with hepatocellular carcinoma (HCC). However, large multicenter studies using this technique have not been reported. Patients and Methods We retrospectively analyzed treatment and survival parameters of 432 cirrhotic patients with nonsurgical early HCC (single nodule ≤ 4 cm or three nodules ≤ 3 cm each) who had received PLA in nine Italian centers. Results Single tumors were seen in 344 (80%) of 432 patients, and two to three nodules were seen in 88 patients (20%), for a total of 548 tumors. An initial complete response after PLA was observed in 338 patients (78%). Median overall survival time was 47 months (95% CI, 41 to 53 months). The 3- and 5-year cumulative survival rates were 61% and 34%, respectively. In multivariate analysis, independent predictors of survival were serum albumin levels more than 3.5 g/dL (P = .002; risk ratio [RR] = 0.580; 95% CI, 0.409 to 0.821), the achievement of a complete tumor ablation (P = .001; RR = 0.517; 95% CI, 0.346 to 0.771), and age less than 73 years (P < .001; RR = 0.466; 95% CI, 0.320 to 0.681). Child-Turcotte-Pugh class A patients had a 5-year cumulative survival rate of 41%; this figure increased up to 60% with a median survival time of 63 months (95% CI, 48 to 78 months) in patients with tumors ≤ 2.0 cm. Conclusion This analysis confirms that a complete tumor ablation results in improved survival in patients with nonsurgical HCC. Ideal candidates for PLA are younger patients with normal serum albumin levels and tumor size ≤ 2 cm.

To retrospectively and prospectively determine the rate and type of complications and their association with clinical or technical factors after percutaneous laser ablation (LA) for hepatocellular carcinoma (HCC).The institutional research board of each center approved the study and all patients provided informed consent. By using an Internet liver tumor database of nine Italian centers, 520 patients were included with HCC nodules of any size (small, 0-3 cm; intermediate,3-5 cm; large,5 cm). Postprocedural complications were related to clinical or percutaneous LA factors by using the Student t and chi(2) tests. Follow-up was carried out with computed tomography (CT) at 1, 3, 6, 9, and 12 months, and primary effectiveness rate was defined as the percentage of HCCs completely ablated after percutaneous LA.A total of 353 men and 147 women (age range, 24-86 years; Child-Pugh score A = 63.4%, B = 30.8%, C = 5.9%) with 647 nodules (mean diameter, 3.2 cm +/- 1.7) were treated by 1004 percutaneous LA sessions. There were four (0.8%) deaths in 520 patients; 15 (1.5%) of 1004 sessions presented major complications without any seeding. Major complications were associated with excess energy (10 520 J +/- 7073 vs 7474 J +/- 3803; P = .001) and high-risk location (P = .05). Sixty-two (6.2%) sessions resulted in minor complications associated with excess energy (P = .001), high bilirubin level (1.74 mg/dL +/- 1.10), and low prothrombin time (P = .01). Primary effectiveness rates were 60% in all HCCs and 81% in HCCs smaller than 3 cm.Percutaneous LA may be considered a safe treatment for small HCCs.

Two thousand and ninety-one ultrasound-guided fine-needle biopsies were performed in 1946 patients to diagnose focal liver lesions. The diagnostic accuracy of fine-needle biopsies is very high (only one false positive was observed), both for aspiration biopsy (93.4%) and for cutting biopsy (95.1%). The difference is not statistically significant. In cases of hepatocellular carcinoma (but not in cases of metastasis or hepatic lymphoma), double biopsy (aspiration and cutting) showed higher diagnostic sensitivity than single methods. A certain number of benign focal liver lesions were also diagnosed. In the present series, no case of death following liver puncture was observed. Intraperitoneal hemorrhage was the most common complication. The risk with a cutting needle being higher than with an aspirative needle.

Objective The aim of this study was to compare the results over time of transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), laser thermal ablation (LTA) and combined therapy in the treatment of small hepatocellular carcinoma. Methods Between 1998 and 2004, 131 cirrhosis patients (99 Child-Pugh class A, 32 Child-Pugh class B) with a small hepatocellular carcinoma were included in the study; 34 were treated with PEI, 46 with LTA, 18 with TACE and 33 with combined therapy. Results No major complication occurred during any procedure. Computed tomography scan showed that complete necrosis was achieved in 81% of treated nodules (120 out of 148); as a whole, the disease relapsed in 42 (32.0%) patients (with a disease-free interval of 17.0 ± 13.7 months). The cumulative survival rates were 81.9, 35.7 and 20.8% at 12, 36 and 60 months respectively. A univariate analysis of survival showed statistically significant differences in the comparison between Child-Pugh class A with respect to Child-Pugh class B (P

Purpose: LTA has been demonstrated a safe and effective image guided ablation technique for HCC only in small series and in selected centers. Aim of this multicentric study was to assess the incidence of LTA complications and associated risk factors in a large population of HCC. Methods and Materials: Retrospective observational study from march 1996 to march 2005 on consecutive HCC patients (9 centers of radiology, internal medicine, gastroenterology) with different experience in LTA and other ablation techniques. An internet based public registry for liver tumor treatments was setup on march 2004 with the collaboration of all the participating centers under the management of one coordinating author (V.A.). Inclusion criteria for this study were: diagnosis of HCC (non surgical), HCC of anynumber and size, ablation treatments with LTA (Pacella CM, Radiology 2001). Demographic characteristics and items related to the patient (Child, prothrombin time, and platelet count,portal hypertension), to HCC nodule (size, site and ease of approach), to LTA procedure (n. of needles/fibers introduced, total energy delivered, necrosis induced) together with the number and type of complications were recorded. Complications were classified as major (death or any condition requiring surgery, interventional procedure or intensive care to be resolved) and minor. Fisher exact, Chi square or Mann-Whitney tests were used for statistic evaluation of association between complications and centers, patients/nodule or LTA characteristics. Results: A total of 520 patients (males 68%, mean age 67.2±7.9% range 24–86yrs; Child score A: 63.4%, B: 30.7%, C: 5.9%) with 652 nodules (single: 69.8%, two: 18.7%, three: 8.6%, four or more: 2.9%; mean diameter 32,3±16.9mm range 6–99mm) were tyreated by 1011 LTA sessions. Major complications were 10/1011 (0.99% with 4 (0.34%) deaths: 3 liver failure and 1 intestinal perforation) not associated with center experience, patient characteristics, nodule features or LTA procedure. Minor complications were 519/1011 (53.1%) LTA sessions and the most frequent were pleural effusion (32.6%), fever (4.9%), pain (4%) and ascites (3.9%). Conclusions: LTA is a safe ablative technique for HCC with low incidence of major complications.

The aim of this study was to compare results over time of Transcatheter Arterial Chemo Embolization (TACE), Percutaneous Ethanol Injection (PEI), Laser Thermal Ablation (LTA) and combined therapy of large Hepatocellular Carcinoma (HCC).Between 1995 and 2003, 89 cirrhosis patients (51 Child-Pugh A, 38 Child-Pugh B) with at least one nodule of HCC =/40 mm, were included in this randomized study; 21 were treated with TACE, 20 with PEI, 29 with LTA and 19 with combined therapy. The total number of HCC nodules was 92 with a mean diameter of 52.9 mm.No major complication occurred in all procedures. CT scan showed that complete necrosis was achieved in 83% of treated nodules (76 out of 92); as a whole, the disease relapsed in 18 (20.2%) patients (disease free interval being 18.2+/-9.4 months). The cumulative survival rates were 69.6%, 25.1% and 9.8% at 12, 36 and 60 months respectively. Univariate analysis of survival showed statistically significant differences in the comparison between Child-Pugh A group vs B (p0.0001) and between single nodule vs multiple (p=0.0019). Patients subjected to combined therapy and LTA showed a statistically significant longer survival than those treated with TACE and PEI.LTA proves to be the most effective treatment for HCC50 mm, combined therapy is the best choice for nodules =/50 mm since complete necrosis is achieved in almost all cases and better total survival in the treated patients.