Aims Colorectal anastomotic strictures affect up to 30% of patients submitted to colo-rectal cancer surgery. However, a complete obstruction is rare. To prevent a surgical revision of the anastomosis, an endoscopic mini-invasive approach may be proposed, but the successful outcome depends on the possibility to pass a guidewire, followed by dilation or placement of a stent through the stricture. In patients with a colostomy if it's not possibile to overcome the stricture, the passage of a guide-wire can be perfomed under echoendoscopic guidance or under direct endoscopic guidance favoured by transillumination through the colonic wall as a reference. The difference between the two methods consists in the filling of the colonic loop in case of echo-endoscopy, or in a simultaneous dual endoscopic procedure in case of transillumination.

Aims This observational study aims to evaluate the technical success, clinical efficacy, and safety of a Peroral Endoscopic Septotomy (POES) variant, named Muscular Tunnelling Peroral Endoscopic Septotomy (MT-POES), for the treatment of Zenker's diverticulum (ZD).

Aims the endoscopic management of rectal lesions displaying scarring or suspected deep submucosal invasion poses a challenging task. Standard endoscopic resection techniques like Full-Thickness Resection Device-assisted (FTRD) and Endoscopic Submucosal Dissection (ESD) present some limitations with these kinds of lesions. FTRD use is constrained by lesion size and location, while ESD is limited in obtaining histologically complete (R0) resections in case of deep submucosal involvement and in resecting scarring lesions. Here we present our initial experience with E-EFTR for the treatment of complex rectal lesions.

Text In this video, we present a novel suturing technique used to close a large rectal wall defect following an exposed endoscopic full-thickness resection of a non-granular 15 mm lateral spreading tumor (LST) in the lower rectum, with suspicion of deep submucosal invasion. The wall defect was closed by grasping the distal eschar's margin with a clip tied with a suture thread, tensioned, and attached alternately to the margins of the defect with additional clips. Finally, the suture was secured with an Overstitch Suture Cinch (Apollo Endosurgery, Austin, Texas). The remaining defect was closed using clips. After one month of follow-up, no adverse events were reported, and the eschar healed completely.

Text Surgical treatment of colo-vaginal fistulae is often contraindicated due to significant morbidity and mortality. We report two cases of elderly women, referred to our centre after the onset of faecaluria and pneumaturia. Both patients had diverticular disease which prevented endoscopic identification of the colonic orifice of the fistula, so an ultrathin gastroscope was inserted into the vagina to identify the vaginal orifice. Using a rendez-vous technique, a hydrophilic guidewire was inserted from the vaginal side of the fistula, retrieved from the colonic side and used to guide a therapeutic gastroscope equipped with an over-the-scope clip, allowing precise deployment of the over-the-scope clip and consequent complete closure of the fistula. Our experience confirms that over-the-scope clip-assisted closure of colo-vaginal fistulae is an effective and feasible treatment option.

Objectives Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality. Design Retrospective multinational study including SCN diagnosed between 1990 and 2014. Results 2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16–99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2–200)), 9% had resection beyond 1 year of follow-up (3 years (1–20), size at diagnosis: 25 mm (4–140)) and 39% had no surgery (3.6 years (1–23), 25.5 mm (1–200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1). Conclusions After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN. Trial registration number IRB 00006477.

Background: There are few data on clinical relevance of adrenal dysfunction and its relationship with occult microbial DNA in noninfected haemodynamically stable cirrhotic patients with ascites.Aims: The aim of this study was to evaluate prognostic role of adrenal dysfunction, microbial DNA, and their relationship.Methods: Adrenal function was assessed in 93 consecutive patients following a corticotropin stimulation test. Adrenal dysfunction was defined as: basal cortisol <10 mu g/dl, delta cortisol <9 mu g/dl, or peak cortisol <18 mu g/dl. Microbial DNA was assessed in blood and ascites of 54 consecutive patients. Patients were followed up until liver transplantation or death.Results: Adrenal dysfunction was not significantly associated with mortality, while the risk of death rose significantly with an increase in basal cortisol values (HR 1.13 per 1-mu l/dl increase; 95% CI 1.01-1.26). Microbial DNA was independently associated with reduced survival (HR 8.05,95% CI 1.57-41.2). In microbial DNA-positive patients a significant correlation was found between Model for End-Stage Liver Disease (MELD) score and basal cortisol values (Pearson's r=0.5107; p=0.018).Conclusions: Microbial DNA and MELD score, but not adrenal function, were the best independent predictors of mortality in noninfected cirrhotic patients with ascites. High serum cortisol levels may be a systemic reaction to microbial translocation, increasing in parallel with deterioration of liver function. (C) 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Background & Aims: We elaborate a non-invasive score system for liver fibrosis (NISF), exploring its diagnostic performance and comparing its accuracy to FibroScan in patients with chronic viral hepatitis (CH) and nonalcoholic fatty liver disease (NAFLD). Methods: Clinical, biochemical, elastographic and ultrasound parameters derived from patients with CH (n = 83) or NAFLD (n = 58), undergoing liver biopsy for fibrosis assessment, were prospectively collected as potential predictors of fibrosis. Each parameter was evaluated for its correlation with the liver biopsy (Gold Standard). Candidate predictors with good interobserver agreement and correlation with histological stages were combined into two algorithms (NISF) to predict fibrosis in chronic viral hepatitis and NAFLD. Results: The CH-NISF included six parameters: bluntness of liver edges, irregularity of left lobe surface, diameter of segment 4, liver stiffness measurement, platelet count and ALT values. The ability of the model to discriminate F3-F4 vs F0-F1 stages and F2 vs F0-F1 was high (AUROC of 0.95 and 0.83 respectively) and better than FibroScan alone, especially in intermediate stages (F2 vs F0-F1), AUROC 0.83 vs 0.57 (P = 0.003). The resulting algorithm is available as mathematical formula, nomogram or free online link. [http://health.mafservizi.it/NISF_Calculator/liver.htm] The NAFLD-NISF included liver stiffness, platelet count and AST levels, had good ability to discriminate F0-F1 vs F2-F3-F4 stages (AUROC 0.86), however, not significantly higher than FibroScan. Conclusions: CH-NISF can be proposed as preliminary and easily available staging tool, superior to FibroScan alone in predicting histological fibrosis, especially in intermediate stages. Further validations are needed to improve NISF accuracy in NAFLD.

Introduction: Accurate and widely available methods for non-invasive assessment of liver fibrosis are increasingly needed in clinical practice.

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/liv.12761 This article is protected by copyright. All rights reserved. Received Date : 24-Jul-2014 Revised Date : 22-Nov-2014 Accepted Date : 02-Dec-2014 Article type : Original Articles

Conclusions: HSC express ActRIIB and respond to myostatin with increased chemotaxis, reduced proliferation, and increased expression of profibrogenic genes

BACKGROUND AND AIMS:Several studies investigated the possible role of adipokines during chronic viral hepatitis, not producing defined results neither clearly establishing their behavior in course of anti-viral treatment. Our study evaluated blood concentrations of adiponectin and resistin in patients with chronic hepatitis C (CHC), B (CHB), and D (CHD) receiving anti-viral treatment, at baseline and after therapy.METHODS:We examined 122 subjects, divided into two groups: 64 patients with chronic hepatitis C virus (HCV) infection (38 males and 26 females, mean age 47.25 yr) and 58 patients including 39 ones with chronic hepatitis B virus (HBV) infection (26 males and 13 females, mean age 48.46 yr) and 19 ones with chronic HBV-hepatitis D virus (HDV) infection (15 males and 4 females, mean age 45.79 yr). Serum levels of adiponectin and resistin were assayed by enzyme-linked immunosorbent assay.RESULTS:In the group of CHC patients we observed a significant decrease in resistin after therapy (p=0.006), while not a significant increase in adiponectin after treatment (p=0.32). Evaluation of changes in adiponectin and resistin levels after anti-viral treatment, both in responders and non-responders, revealed no significant variations. In the group of HBV+ and HBV-HDV+ patients, we found a decrease in resistin after therapy (p=0.0016) and a not significant reduction in adiponectin after treatment (p=0.13). Furthermore, we noticed a significant reduction of resistin (p=0.006) in the sub-group of responders.CONCLUSIONS:Our data suggested the possible marker role of adiponectin and resistin in the inflammatory process in course of chronic viral hepatitis.