Pancreatic adenocarcinoma(PDAC)is one of the most common and lethal human cancers worldwide.Surgery followed by adjuvant chemotherapy offers the best chance of a long-term survival for patients with PDAC,although only...Pancreatic adenocarcinoma(PDAC)is one of the most common and lethal human cancers worldwide.Surgery followed by adjuvant chemotherapy offers the best chance of a long-term survival for patients with PDAC,although only approximately 20%of the patients have resectable tumors when diagnosed.Neoadjuvant chemotherapy(NACT)is recommended for borderline resectable pancreatic cancer.Several studies have investigated the role of NACT in treating resectable tumors based on the recent advances in PDAC biology,as NACT provides the potential benefit of selecting patients with favorable tumor biology and controls potential micro-metastases in high-risk patients with resectable PDAC.In such challenging cases,new potential tools,such as ct-DNA and molecular targeted therapy,are emerging as novel therapeutic options that may improve old paradigms.This review aims to summarize the current evidence regarding the role of NACT in treating non-metastatic pancreatic cancer while focusing on future perspectives in light of recent evidence.展开更多
Studies have reported on the economic impacts of clinical and subclinical mastitis on dairy farms.Bovine mastitis is a disorder that affects dairy farms and has a major economic impact.Most of the economic losses are ...Studies have reported on the economic impacts of clinical and subclinical mastitis on dairy farms.Bovine mastitis is a disorder that affects dairy farms and has a major economic impact.Most of the economic losses are the result of mastitis.Mastitis is an invasive infection that is among the most numerous and highly complicated infections in the dairy sector.Mastitis is one of the most expensive diseases in terms of production losses among animal diseases.Mastitis reduces milk production,changes milk composition,and shortens the productive life of infected cows.Farmers must concentrate on avoiding mastitis infection whilst putting in place and following a mastitis control programed.Bovine mastitis,the most significant disease of dairy herds,has huge effects on farm economics.Mastitis losses are due to reduced milk production,the cost of treatments,and culling.Major factors related to low milk yield could be low genetic potential as well as poor nutritional and managerial approaches.Most of the losses are related to somatic cell count(SCC),which is characterised by an increase in the percentage of milk.Culling costs are the costs of rearing or buying a replacement animal,mostly heifers.Overhead impacts include the replacement animals'lower milk supply effectiveness.The expense of replacing animals prematurely due to mastitis is one of the most significant areas of economic loss.展开更多
Based on the available literature,non alcoholic fatty liver disease or generally speaking,hepatic steatosis,is more frequent among people with diabetes and obesity,and is almost universally present amongst morbidly ob...Based on the available literature,non alcoholic fatty liver disease or generally speaking,hepatic steatosis,is more frequent among people with diabetes and obesity,and is almost universally present amongst morbidly obese diabetic patients.Non alcoholic fatty liver disease is being increasingly recognized as a common liver condition in the developed world,with non alcoholic steatohepatitis projected to be the leading cause of liver transplantation.Previous data report that only 20%of patients with Cushing’s syndrome have hepatic steatosis.Aiming at clarifying the reasons whereby patients suffering from Cushing’s syndrome-a condition characterized by profound metabolic changes-present low prevalence of hepatic steatosis,the Authors reviewed the current concepts on the link between hypercortisolism and obesity/metabolic syndrome.They hypothesize that this low prevalence of fat accumulation in the liver of patients with Cushing’s syndrome could result from the inhibition of the so-called low-grade chronicinflammation,mainly mediated by Interleukin 6,due to an excess of cortisol,a hormone characterized by an anti-inflammatory effect.The Cushing’s syndrome,speculatively considered as an in vivo model of the hepatic steatosis,could also help clarify the mechanisms of non alcoholic fatty liver disease.展开更多
Hypervigilance and symptoms anticipation,visceral hypersensitivity and gastroduodenal sensorimotor abnormalities account for the varied clinical presentation of functional dyspepsia(FD)patients.Many patients recognize...Hypervigilance and symptoms anticipation,visceral hypersensitivity and gastroduodenal sensorimotor abnormalities account for the varied clinical presentation of functional dyspepsia(FD)patients.Many patients recognize meals as the main triggering factor;thus,dietary manipulations often represent the first-line management strategy in this cohort of patients.Nonetheless,scarce quality evidence has been produced regarding the relationship between specific foods and/or macronutrients and the onset of FD symptoms,resulting in nonstandardized nutritional approaches.Most dietary advises are indeed empirical and often lead to exclusion diets,reinforcing in patients the perception of“being intolerant”to food and self-perpetuating some of the very mechanisms underlying dyspepsia physiopathology(i.e.,hypervigilance and symptom anticipation).Clinicians are often uncertain regarding the contribution of specific foods to dyspepsia physiopathology and dedicated professionals(i.e.,dietitians)are only available in tertiary referral settings.This in turn,can result in nutritionally unbalanced diets and could even encourage restrictive eating behaviors in severe dyspepsia.In this review,we aim at evaluating the relationship between dietary habits,macronutrients and specific foods in determining FD symptoms.We will provide an overview of the evidence-based nutritional approach that should be pursued in these patients,providing clinicians with a valuable tool in standardizing nutritional advises and discouraging patients from engaging into indiscriminate food exclusions.展开更多
Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Over...Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro-and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related comorbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multivitamins and mineral supplements according to the patient's needs.展开更多
Spontaneous bacterial peritonitis(SBP) is the most common infection in end-stage liver disease patients.SBP is defined as an ascitic fluid infection with a polymorphonuclear leucocyte count ≥ 250/mm^3 without an evid...Spontaneous bacterial peritonitis(SBP) is the most common infection in end-stage liver disease patients.SBP is defined as an ascitic fluid infection with a polymorphonuclear leucocyte count ≥ 250/mm^3 without an evident intra-abdominal surgically treatable source.Several mechanisms contribute to SBP occurrence,including translocation of gut bacteria and their products,reduced intestinal motility provoking bacterial overgrowth,alteration of the gut's barrier function and local immune responses.Historically,Gram-negative enteric bacteria have been the main causative agents of SBP,thereby guiding the empirical therapeutic choice.However,over the last decade,a worryingly increasing prevalence of Gram-positive and multi-drug resistant(MDR) SBP has been seen.Recently,the microbiological spectrum of SBP seems to have changed in Europe due to a high prevalence of Gram-positive bacteria(48%-62%).The overall proportion of MDR bacteria is up to 22%-73% of cases.Consequently,empirical therapy based on thirdgeneration cephalosporins or amoxicillin/clavulanic acid,can no longer be considered the standard of care,as these drugs are associated with poor outcomes.Theaim of this review is to describe,with an epidemiological focus,the evidence behind this rise in Gram-positive and MDR SBP from 2000 to present,and illustrate potential targeted therapeutic strategies.An appropriate treatment protocol should include daptomycin plus ceftaroline and meropenem,with prompt stepdown to a narrower spectrum when cultures and sensitivity data are available in order to reduce both cost and potential antibiotic resistance development.展开更多
Although the prevalence of gastric cancer(GC) progressively decreased during the last decades,due to improved dietary habit,introduction of food refrigeration and recovered socio-economic level,it still accounts for 1...Although the prevalence of gastric cancer(GC) progressively decreased during the last decades,due to improved dietary habit,introduction of food refrigeration and recovered socio-economic level,it still accounts for 10% of the total cancer-related deaths. The best strategy to reduce the mortality for GC is to schedule appropriate screening and surveillance programs,that rises many relevant concerns taking into account its worldwide variability,natural history,diagnostic tools,therapeutic strategies,and cost-effectiveness. Intestinal-type,the most frequent GC histotype,develops through a multistep process triggered by Helicobacter pylori(H. pylori) and progressing from gastritis to atrophy,intestinal metaplasia(IM),and dysplasia. However,the majority of patients infected with H. pylori and carrying premalignant lesions do not develop GC. Therefore,it remains unclear who should be screened,when the screening should be started and how the screening should be performed. It seems reasonable that screening programs should target the general population in eastern countries,at high prevalence of GC and the high-risk subjects in western countries,at low prevalence of GC.As far as concern surveillance,currently,we are lacking of standardized international recommendations and many features have to be defined regarding the optimal diagnostic approach,the patients at higher risk,the best timing and the cost-effectiveness.Anyway,patients with corpus atrophic gastritis,extensive incomplete IM and dysplasia should enter a surveillance program.At present,screening and surveillance programs need further studies to draw worldwide reliable recommendations and evaluate the impact on mortality for GC.展开更多
Colorectal cancer(CRC)is the third most common malignancy worldwide,with approximately 50%of patients developing colorectal cancer liver metastasis(CRLM)during the follow-up period.Management of CRLM is best achieved ...Colorectal cancer(CRC)is the third most common malignancy worldwide,with approximately 50%of patients developing colorectal cancer liver metastasis(CRLM)during the follow-up period.Management of CRLM is best achieved via a multidisciplinary approach and the diagnostic and therapeutic decision-making process is complex.In order to optimize patients’survival and quality of life,there are several unsolved challenges which must be overcome.These primarily include a timely diagnosis and the identification of reliable prognostic factors.Furthermore,to allow optimal treatment options,a precision-medicine,personalized approach is required.The widespread digitalization of healthcare generates a vast amount of data and together with accessible high-performance computing,artificial intelligence(AI)technologies can be applied.By increasing diagnostic accuracy,reducing timings and costs,the application of AI could help mitigate the current shortcomings in CRLM management.In this review we explore the available evidence of the possible role of AI in all phases of the CRLM natural history.Radiomics analysis and convolutional neural networks(CNN)which combine computed tomography(CT)images with clinical data have been developed to predict CRLM development in CRC patients.AI models have also proven themselves to perform similarly or better than expert radiologists in detecting CRLM on CT and magnetic resonance scans or identifying them from the noninvasive analysis of patients’exhaled air.The application of AI and machine learning(ML)in diagnosing CRLM has also been extended to histopathological examination in order to rapidly and accurately identify CRLM tissue and its different histopathological growth patterns.ML and CNN have shown good accuracy in predicting response to chemotherapy,early local tumor progression after ablation treatment,and patient survival after surgical treatment or chemotherapy.Despite the initial enthusiasm and the accumulating evidence,AI technologies’role in healthcare and CRLM management is not yet fully established.Its limitations mainly concern safety and the lack of regulation and ethical considerations.AI is unlikely to fully replace any human role but could be actively integrated to facilitate physicians in their everyday practice.Moving towards a personalized and evidence-based patient approach and management,further larger,prospective and rigorous studies evaluating AI technologies in patients at risk or affected by CRLM are needed.展开更多
AIM: To investigate spleen status in psoriasis and itsrelationship with hepatic steatosis, Psoriasis Area and Severity Index, and insulin resistance.METHODS: Seventy-nine psoriatic patients who were not suffering from...AIM: To investigate spleen status in psoriasis and itsrelationship with hepatic steatosis, Psoriasis Area and Severity Index, and insulin resistance.METHODS: Seventy-nine psoriatic patients who were not suffering from any chronic inflammatory disease were retrospectively selected for inclusion in this study,and their complete medical records were accessed.An age- and sex-matched group of 80 non-psoriatic,obese patients was included as a control. The following relevant data were collected: age, sex, weight, height,body mass index, waist circumference, blood pressure,insulin resistance status, age at psoriasis onset, and severity of psoriasis. Abdominal ultrasonography was performed to determine spleen longitudinal diameter(SLD), and hepatic steatosis grade.RESULTS: The SLD of control obese patients was greater than that of psoriatic subjects(P = 0.013),but body mass index predicted the size of the spleen in psoriatic patients(P < 0.001). The SLD of psoriatic patients with normal weight was significantly reduced with respect to the overweight/obese psoriatic patients(P = 0.002). A multiple regression analysis revealed that body mass index was a unique predictor of the spleen size(P < 0.001). Finally, the disease duration predicted the spleen size in psoriatic subjects(P =0.038).CONCLUSION: This study shows a correlation between the SLD and the duration of psoriasis.展开更多
Early diagnosis of Parkinson’s disease(PD):how we can improve the therapeutic approach:PD is a neurodegenerative disease characterized by motor dysfunctions(tremor,rigidity,bradykinesia and impaired posture/balance)e...Early diagnosis of Parkinson’s disease(PD):how we can improve the therapeutic approach:PD is a neurodegenerative disease characterized by motor dysfunctions(tremor,rigidity,bradykinesia and impaired posture/balance)elicited by selective depletion of dopaminergic(DA)neurons in substantia nigra pars compacta.DA neuron loss is associated with neuronal inclusions of the phosphorylatedα-synuclein protein called Lewy body(Shults,2006).Although the underlying neurodegenerative process is not affected,the management of PD patients has been revolutionized with the introduction of levodopa and DA drugs in the routine therapy,which ensures initial symptomatic relief of motor functions through the DA supply in the nigrostriatal circuit.These drugs are currently the best option for treating PD,although their chronic use is associated with progressive dopamine resistance and loss of effectiveness in the recovery of motor dysfunctions.Alternative therapeutic strategies,including agonists of DA receptors,monoamine oxide B inhibitors,and even deep brain stimulation techniques have been developed to overcome these clinical limitations.Unfortunately,these therapeutic approaches cannot restore PD-compromised functions,as irreversible DA neurodegeneration has occurred in substantia nigra pars compacta when first motor symptoms appear.The nigrostriatal system is traditionally considered as the first region affected by neuronal impairment in Parkinsonisms;however,α-synuclein aggregation appears in a pre-motor stage of the disease in the enteric nervous system(ENS).展开更多
Obesity is an increasingly serious health problem in nearly all Western countries.It represents an important risk factor for several gastrointestinal diseases,such as gastroesophageal reflux disease,erosive esophagiti...Obesity is an increasingly serious health problem in nearly all Western countries.It represents an important risk factor for several gastrointestinal diseases,such as gastroesophageal reflux disease,erosive esophagitis,hiatal hernia,Barrett’s esophagus,esophageal adenocarcinoma,Helicobacter pylori infection,colorectal polyps and cancer,non-alcoholic fatty liver disease,cirrhosis,and hepatocellular carcinoma.Surgery is the most effective treatment to date,resulting in sustainable and significant weight loss,along with the resolution of metabolic comorbidities in up to 80%of cases.Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery.There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings,such as large hiatal hernia or Barrett’s esophagus,are detected preoperatively.The value of a routine endoscopy before bariatric surgery in asymptomatic patients(screening esophagogastroduodenoscopy)remains controversial.The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms,the management of complications,and the evaluation of weight loss failure.It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting.The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.展开更多
AIM: To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC) placement.METHODS: We retrospectively enrolled 20 patients(13 female and 7 male; m...AIM: To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC) placement.METHODS: We retrospectively enrolled 20 patients(13 female and 7 male; mean age: 70.6 ± 9.8 years) in eight high-volume tertiary referral centers with upper or lower iatrogenic gastrointestinal tract perforation treated by OTSC placement. Gastrointestinal tract perforation could be with oval-shape or with round-shape. Ovalshape perforations were closed by OTSC only by suction and the round-shape by the "twin-grasper" plus suction. RESULTS: Main perforation diameter was 10.1 ± 4.3 mm(range 3-18 mm). The technical success rate was 100%(20/20 patients) and the clinical success rate was 90%(18/20 patients). Two patients(10%) who did not have complete sealing of the defect underwent surgery. Based upon our observations we propose two types of perforation: Round-shape "type-1 perforation" and oval-shape "type-2 perforation". Eight(40%) out of the 20 patients had a type-1 perforation and 12 patients a type-2(60%). CONCLUSION: OTSC placement should be attempted after perforation occurring during diagnostic or therapeutic endoscopy. A failed closure attempt does not impair subsequent surgical treatment.展开更多
Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision(TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radi...Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision(TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques(pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.展开更多
Pancreatic vipoma is an extremely rare tumor accounting for less than 2% of endocrine pancreatic neoplasms with a reported incidence of 0.1-0.6 per million. While cross-sectional imaging findings are usually not speci...Pancreatic vipoma is an extremely rare tumor accounting for less than 2% of endocrine pancreatic neoplasms with a reported incidence of 0.1-0.6 per million. While cross-sectional imaging findings are usually not specific, exact localization of the tumor by means of either computed tomography(CT) or magnetic resonance(MR) is pivotal for surgical planning. However, cross-sectional imaging findings are usually not specific and further characterization of the tumor may only be achieved bysomatostatin-receptor scintigraphy(SRS). We report the case of a 70 years old female with a two years history of watery diarrhoea who was found to have a solid, inhomogeneously enhancing lesion at the level of the pancreatic tail at Gadolinium-enhanced MR(Somatom Trio 3T, Siemens, Germany). The tumor had been prospectively overlooked at a contrast-enhanced multi-detector CT(Aquilion 64, Toshiba, Japan) performed after i.v. bolus injection of only 100 cc of iodinated non ionic contrast media because of a chronic renal failure(3.4 mg/mL) but it was subsequently confirmed by SRS. The patient first underwent a successful symptomatic treatment with somatostatin analogues and was then submitted to a distal pancreasectomy with splenectomy to remove a capsulated whitish tumor which turned out to be a well-differentiated vipoma at histological and immuno-histochemical analysis.展开更多
Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),causing coronavirus disease 2019(COVID-19),can trigger autoimmunity in genetically predisposed individuals through hyperstimulation of immune response and mo...Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),causing coronavirus disease 2019(COVID-19),can trigger autoimmunity in genetically predisposed individuals through hyperstimulation of immune response and molecular mimicry.Here we summarise the current knowledge about autoimmune liver diseases(AILDs)and SARS-CoV-2,focusing on:(1)The risk of SARS-CoV-2 infection and the course of COVID-19 in patients affected by AILDs;(2)the role of SARS-CoV-2 in inducing liver damage and triggering AILDs;and(3)the ability of vaccines against SARS-CoV-2 to induce autoimmune responses in the liver.Data derived from the literature suggest that patients with AILDs do not carry an increased risk of SARS-Cov-2 infection but may develop a more severe course of COVID-19 if on treatment with steroids or thiopurine.Although SARSCoV-2 infection can lead to the development of several autoimmune diseases,few reports correlate it to the appearance of de novo manifestation of immunemediated liver diseases such as autoimmune hepatitis(AIH),primary biliary cholangitis(PBC)or AIH/PBC overlap syndrome.Different case series of an AIHlike syndrome with a good prognosis after SARS-CoV-2 vaccination have been described.Although the causal link between SARS-CoV-2 vaccines and AIH cannot be definitively established,these reports suggest that this association could be more than coincidental.展开更多
Staphylococcus aureus is an important zoonotic pathogen that is responsible for a variety of infectious diseases in humans and animals.The present study was designed to check the prevalence and antimicrobial resistanc...Staphylococcus aureus is an important zoonotic pathogen that is responsible for a variety of infectious diseases in humans and animals.The present study was designed to check the prevalence and antimicrobial resistance of MSSA from three different animal origins(bovine,caprine and pet).A total of n=450 samples(150 each source)were collected from bovine,caprine and pets.Collected samples were subjected to S.aureus identification by microbiological examination and confirmed S.aureus isolates were put to oxacillin disk diffusion test to declare them MSSA.The MSSA confirmed isolates were subjected to various antibiotics for susceptibility profiling using Kirby Bauer Disk Diffusion test.The present study found higher prevalence of MSSA from caprine origin(goat 83.33%)as compared to pet(cat 69.33%;dog 65.33%)and bovine origin(buffalo 26.66%;cattle 31.66%).The in-vitro findings of current study revealed oxytetracycline and gentamicin presented 100%efficacy against MSSA of all origins while the vancomycin presented>35%,>40%and>65%resistance against MSSA isolated from bovine,caprine and pet origin respectively.However,ciprofloxacin was equally effective(50%)against MSSA from buffalo and cattle while>80%efficacy was noted against MSSA from cat and dogs.Linezolid and amoxicillin+clavulanic acid were 77.78%and 66.67%sensitive to MSSA isolates from caprine milk.The present study found higher prevalence of MSSA from bovine,caprine and pet isolates with diversified pattern of susceptibility of different antibiotics from all sources.展开更多
The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%,depending on the patient's age.Development of Endoscopic Retrograde Cholangiopancreatography and...The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%,depending on the patient's age.Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones.At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include:single-stage laparoscopic treatment,perioperative endoscopic treatment and endoscopic treatment alone.Published data evidence that,associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay.However,current data does not suggest clear superiority of any one approach with regard to success,mortality,morbidity and cost-effectiveness.Considering the variety of therapeutic options available for management,a critical appraisal and decision-making is required.endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis,i.e.,in patients with acute obstructive suppurative cholangitis,severe biliary pancreatitis,ampullary stone impaction or severe comorbidity.In a setting where all facilities are available,decision in the selection of the therapeutic option depends on the patients,the number and size of choledocholithiasis stones,the anatomy of the cystic duct and common bile duct,the surgical history of patients and local expertise.展开更多
The harmful use of alcohol is a worldwide problem.It has been estimated that alcohol abuse represents the world’s third largest risk factor for disease and disability;it is a causal factor of 60 types of diseases and...The harmful use of alcohol is a worldwide problem.It has been estimated that alcohol abuse represents the world’s third largest risk factor for disease and disability;it is a causal factor of 60 types of diseases and injuries and a concurrent cause of at least 200 others.Liver is the main organ responsible for metabolizing ethanol,thus it has been considered for long time the major victim of the harmful use of alcohol.Ethanol and its bioactive products,acetaldehyde-acetate,fatty acid ethanol esters,ethanol-protein adducts,have been regarded as hepatotoxins that directly and indirectly exert their toxic effect on the liver.A similar mechanism has been postulated for the alcohol-related pancreatic damage.Alcohol and its metabolites directly injure acinar cells and elicit stellate cells to produce and deposit extracellular matrix thus triggering the"necrosis-fibrosis"sequence that finally leads to atrophy and fibrosis,morphological hallmarks of alcoholic chronic pancreatitis.Even if less attention has been paid to the upper and lower gastrointestinal tract,ethanol produces harmful effects by inducing:(1)direct damaging of the mucosa of the esophagus and stomach;(2)modification of thesphincterial pressure and impairment of motility;and(3)alteration of gastric acid output.In the intestine,ethanol can damage the intestinal mucosa directly or indirectly by altering the resident microflora and impairing the mucosal immune system.Notably,disruption of the intestinal mucosal barrier of the small and large intestine contribute to liver damage.This review summarizes the most clinically relevant alcohol-related diseases of the digestive tract focusing on the pathogenic mechanisms by which ethanol damages liver,pancreas and gastrointestinal tract.展开更多
Endoscopic papillectomy(EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indicatio...Endoscopic papillectomy(EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size(up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings(ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound(EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a "high-risk'' procedure due to complications. Complications of endoscopic papillectomy can be classified as early(pancreatitis, bleeding, perforation, and cholangitis) and late(papil-lary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis(FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.展开更多
The present study was designed to alert the public opinion and policy makers on the supposed enhancing effects of exposure to ambient air particulate matter with aerodynamic diameters < 2.5 mm (PM 2.5 ) on non-alco...The present study was designed to alert the public opinion and policy makers on the supposed enhancing effects of exposure to ambient air particulate matter with aerodynamic diameters < 2.5 mm (PM 2.5 ) on non-alcoholic fatty liver disease (NAFLD), the most common chronic liver disease in Western countries. For far too long literature data have been fixated on pulmonary diseases and/or cardiovascular disease, as consequence of particulate exposure, ignoring the link between the explosion of obesity with related syndromes such as NAFLD and air pollution, the worst characteristics of nowadays civilization. In order to delineate a clear picture of this major health problem, further studies should investigate whether and at what extent cigarette smoking and exposure to ambient air PM 2.5 impact the natural history of patients with obesity-related NAFLD,i.e. , development of non alcoholic steatohepatitis, disease characterized by a worse prognosis due its progression towards fibrosis and hepatocarcinoma.展开更多
文摘Pancreatic adenocarcinoma(PDAC)is one of the most common and lethal human cancers worldwide.Surgery followed by adjuvant chemotherapy offers the best chance of a long-term survival for patients with PDAC,although only approximately 20%of the patients have resectable tumors when diagnosed.Neoadjuvant chemotherapy(NACT)is recommended for borderline resectable pancreatic cancer.Several studies have investigated the role of NACT in treating resectable tumors based on the recent advances in PDAC biology,as NACT provides the potential benefit of selecting patients with favorable tumor biology and controls potential micro-metastases in high-risk patients with resectable PDAC.In such challenging cases,new potential tools,such as ct-DNA and molecular targeted therapy,are emerging as novel therapeutic options that may improve old paradigms.This review aims to summarize the current evidence regarding the role of NACT in treating non-metastatic pancreatic cancer while focusing on future perspectives in light of recent evidence.
文摘Studies have reported on the economic impacts of clinical and subclinical mastitis on dairy farms.Bovine mastitis is a disorder that affects dairy farms and has a major economic impact.Most of the economic losses are the result of mastitis.Mastitis is an invasive infection that is among the most numerous and highly complicated infections in the dairy sector.Mastitis is one of the most expensive diseases in terms of production losses among animal diseases.Mastitis reduces milk production,changes milk composition,and shortens the productive life of infected cows.Farmers must concentrate on avoiding mastitis infection whilst putting in place and following a mastitis control programed.Bovine mastitis,the most significant disease of dairy herds,has huge effects on farm economics.Mastitis losses are due to reduced milk production,the cost of treatments,and culling.Major factors related to low milk yield could be low genetic potential as well as poor nutritional and managerial approaches.Most of the losses are related to somatic cell count(SCC),which is characterised by an increase in the percentage of milk.Culling costs are the costs of rearing or buying a replacement animal,mostly heifers.Overhead impacts include the replacement animals'lower milk supply effectiveness.The expense of replacing animals prematurely due to mastitis is one of the most significant areas of economic loss.
文摘Based on the available literature,non alcoholic fatty liver disease or generally speaking,hepatic steatosis,is more frequent among people with diabetes and obesity,and is almost universally present amongst morbidly obese diabetic patients.Non alcoholic fatty liver disease is being increasingly recognized as a common liver condition in the developed world,with non alcoholic steatohepatitis projected to be the leading cause of liver transplantation.Previous data report that only 20%of patients with Cushing’s syndrome have hepatic steatosis.Aiming at clarifying the reasons whereby patients suffering from Cushing’s syndrome-a condition characterized by profound metabolic changes-present low prevalence of hepatic steatosis,the Authors reviewed the current concepts on the link between hypercortisolism and obesity/metabolic syndrome.They hypothesize that this low prevalence of fat accumulation in the liver of patients with Cushing’s syndrome could result from the inhibition of the so-called low-grade chronicinflammation,mainly mediated by Interleukin 6,due to an excess of cortisol,a hormone characterized by an anti-inflammatory effect.The Cushing’s syndrome,speculatively considered as an in vivo model of the hepatic steatosis,could also help clarify the mechanisms of non alcoholic fatty liver disease.
文摘Hypervigilance and symptoms anticipation,visceral hypersensitivity and gastroduodenal sensorimotor abnormalities account for the varied clinical presentation of functional dyspepsia(FD)patients.Many patients recognize meals as the main triggering factor;thus,dietary manipulations often represent the first-line management strategy in this cohort of patients.Nonetheless,scarce quality evidence has been produced regarding the relationship between specific foods and/or macronutrients and the onset of FD symptoms,resulting in nonstandardized nutritional approaches.Most dietary advises are indeed empirical and often lead to exclusion diets,reinforcing in patients the perception of“being intolerant”to food and self-perpetuating some of the very mechanisms underlying dyspepsia physiopathology(i.e.,hypervigilance and symptom anticipation).Clinicians are often uncertain regarding the contribution of specific foods to dyspepsia physiopathology and dedicated professionals(i.e.,dietitians)are only available in tertiary referral settings.This in turn,can result in nutritionally unbalanced diets and could even encourage restrictive eating behaviors in severe dyspepsia.In this review,we aim at evaluating the relationship between dietary habits,macronutrients and specific foods in determining FD symptoms.We will provide an overview of the evidence-based nutritional approach that should be pursued in these patients,providing clinicians with a valuable tool in standardizing nutritional advises and discouraging patients from engaging into indiscriminate food exclusions.
文摘Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro-and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related comorbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multivitamins and mineral supplements according to the patient's needs.
文摘Spontaneous bacterial peritonitis(SBP) is the most common infection in end-stage liver disease patients.SBP is defined as an ascitic fluid infection with a polymorphonuclear leucocyte count ≥ 250/mm^3 without an evident intra-abdominal surgically treatable source.Several mechanisms contribute to SBP occurrence,including translocation of gut bacteria and their products,reduced intestinal motility provoking bacterial overgrowth,alteration of the gut's barrier function and local immune responses.Historically,Gram-negative enteric bacteria have been the main causative agents of SBP,thereby guiding the empirical therapeutic choice.However,over the last decade,a worryingly increasing prevalence of Gram-positive and multi-drug resistant(MDR) SBP has been seen.Recently,the microbiological spectrum of SBP seems to have changed in Europe due to a high prevalence of Gram-positive bacteria(48%-62%).The overall proportion of MDR bacteria is up to 22%-73% of cases.Consequently,empirical therapy based on thirdgeneration cephalosporins or amoxicillin/clavulanic acid,can no longer be considered the standard of care,as these drugs are associated with poor outcomes.Theaim of this review is to describe,with an epidemiological focus,the evidence behind this rise in Gram-positive and MDR SBP from 2000 to present,and illustrate potential targeted therapeutic strategies.An appropriate treatment protocol should include daptomycin plus ceftaroline and meropenem,with prompt stepdown to a narrower spectrum when cultures and sensitivity data are available in order to reduce both cost and potential antibiotic resistance development.
文摘Although the prevalence of gastric cancer(GC) progressively decreased during the last decades,due to improved dietary habit,introduction of food refrigeration and recovered socio-economic level,it still accounts for 10% of the total cancer-related deaths. The best strategy to reduce the mortality for GC is to schedule appropriate screening and surveillance programs,that rises many relevant concerns taking into account its worldwide variability,natural history,diagnostic tools,therapeutic strategies,and cost-effectiveness. Intestinal-type,the most frequent GC histotype,develops through a multistep process triggered by Helicobacter pylori(H. pylori) and progressing from gastritis to atrophy,intestinal metaplasia(IM),and dysplasia. However,the majority of patients infected with H. pylori and carrying premalignant lesions do not develop GC. Therefore,it remains unclear who should be screened,when the screening should be started and how the screening should be performed. It seems reasonable that screening programs should target the general population in eastern countries,at high prevalence of GC and the high-risk subjects in western countries,at low prevalence of GC.As far as concern surveillance,currently,we are lacking of standardized international recommendations and many features have to be defined regarding the optimal diagnostic approach,the patients at higher risk,the best timing and the cost-effectiveness.Anyway,patients with corpus atrophic gastritis,extensive incomplete IM and dysplasia should enter a surveillance program.At present,screening and surveillance programs need further studies to draw worldwide reliable recommendations and evaluate the impact on mortality for GC.
文摘Colorectal cancer(CRC)is the third most common malignancy worldwide,with approximately 50%of patients developing colorectal cancer liver metastasis(CRLM)during the follow-up period.Management of CRLM is best achieved via a multidisciplinary approach and the diagnostic and therapeutic decision-making process is complex.In order to optimize patients’survival and quality of life,there are several unsolved challenges which must be overcome.These primarily include a timely diagnosis and the identification of reliable prognostic factors.Furthermore,to allow optimal treatment options,a precision-medicine,personalized approach is required.The widespread digitalization of healthcare generates a vast amount of data and together with accessible high-performance computing,artificial intelligence(AI)technologies can be applied.By increasing diagnostic accuracy,reducing timings and costs,the application of AI could help mitigate the current shortcomings in CRLM management.In this review we explore the available evidence of the possible role of AI in all phases of the CRLM natural history.Radiomics analysis and convolutional neural networks(CNN)which combine computed tomography(CT)images with clinical data have been developed to predict CRLM development in CRC patients.AI models have also proven themselves to perform similarly or better than expert radiologists in detecting CRLM on CT and magnetic resonance scans or identifying them from the noninvasive analysis of patients’exhaled air.The application of AI and machine learning(ML)in diagnosing CRLM has also been extended to histopathological examination in order to rapidly and accurately identify CRLM tissue and its different histopathological growth patterns.ML and CNN have shown good accuracy in predicting response to chemotherapy,early local tumor progression after ablation treatment,and patient survival after surgical treatment or chemotherapy.Despite the initial enthusiasm and the accumulating evidence,AI technologies’role in healthcare and CRLM management is not yet fully established.Its limitations mainly concern safety and the lack of regulation and ethical considerations.AI is unlikely to fully replace any human role but could be actively integrated to facilitate physicians in their everyday practice.Moving towards a personalized and evidence-based patient approach and management,further larger,prospective and rigorous studies evaluating AI technologies in patients at risk or affected by CRLM are needed.
文摘AIM: To investigate spleen status in psoriasis and itsrelationship with hepatic steatosis, Psoriasis Area and Severity Index, and insulin resistance.METHODS: Seventy-nine psoriatic patients who were not suffering from any chronic inflammatory disease were retrospectively selected for inclusion in this study,and their complete medical records were accessed.An age- and sex-matched group of 80 non-psoriatic,obese patients was included as a control. The following relevant data were collected: age, sex, weight, height,body mass index, waist circumference, blood pressure,insulin resistance status, age at psoriasis onset, and severity of psoriasis. Abdominal ultrasonography was performed to determine spleen longitudinal diameter(SLD), and hepatic steatosis grade.RESULTS: The SLD of control obese patients was greater than that of psoriatic subjects(P = 0.013),but body mass index predicted the size of the spleen in psoriatic patients(P < 0.001). The SLD of psoriatic patients with normal weight was significantly reduced with respect to the overweight/obese psoriatic patients(P = 0.002). A multiple regression analysis revealed that body mass index was a unique predictor of the spleen size(P < 0.001). Finally, the disease duration predicted the spleen size in psoriatic subjects(P =0.038).CONCLUSION: This study shows a correlation between the SLD and the duration of psoriasis.
文摘Early diagnosis of Parkinson’s disease(PD):how we can improve the therapeutic approach:PD is a neurodegenerative disease characterized by motor dysfunctions(tremor,rigidity,bradykinesia and impaired posture/balance)elicited by selective depletion of dopaminergic(DA)neurons in substantia nigra pars compacta.DA neuron loss is associated with neuronal inclusions of the phosphorylatedα-synuclein protein called Lewy body(Shults,2006).Although the underlying neurodegenerative process is not affected,the management of PD patients has been revolutionized with the introduction of levodopa and DA drugs in the routine therapy,which ensures initial symptomatic relief of motor functions through the DA supply in the nigrostriatal circuit.These drugs are currently the best option for treating PD,although their chronic use is associated with progressive dopamine resistance and loss of effectiveness in the recovery of motor dysfunctions.Alternative therapeutic strategies,including agonists of DA receptors,monoamine oxide B inhibitors,and even deep brain stimulation techniques have been developed to overcome these clinical limitations.Unfortunately,these therapeutic approaches cannot restore PD-compromised functions,as irreversible DA neurodegeneration has occurred in substantia nigra pars compacta when first motor symptoms appear.The nigrostriatal system is traditionally considered as the first region affected by neuronal impairment in Parkinsonisms;however,α-synuclein aggregation appears in a pre-motor stage of the disease in the enteric nervous system(ENS).
文摘Obesity is an increasingly serious health problem in nearly all Western countries.It represents an important risk factor for several gastrointestinal diseases,such as gastroesophageal reflux disease,erosive esophagitis,hiatal hernia,Barrett’s esophagus,esophageal adenocarcinoma,Helicobacter pylori infection,colorectal polyps and cancer,non-alcoholic fatty liver disease,cirrhosis,and hepatocellular carcinoma.Surgery is the most effective treatment to date,resulting in sustainable and significant weight loss,along with the resolution of metabolic comorbidities in up to 80%of cases.Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery.There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings,such as large hiatal hernia or Barrett’s esophagus,are detected preoperatively.The value of a routine endoscopy before bariatric surgery in asymptomatic patients(screening esophagogastroduodenoscopy)remains controversial.The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms,the management of complications,and the evaluation of weight loss failure.It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting.The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.
文摘AIM: To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC) placement.METHODS: We retrospectively enrolled 20 patients(13 female and 7 male; mean age: 70.6 ± 9.8 years) in eight high-volume tertiary referral centers with upper or lower iatrogenic gastrointestinal tract perforation treated by OTSC placement. Gastrointestinal tract perforation could be with oval-shape or with round-shape. Ovalshape perforations were closed by OTSC only by suction and the round-shape by the "twin-grasper" plus suction. RESULTS: Main perforation diameter was 10.1 ± 4.3 mm(range 3-18 mm). The technical success rate was 100%(20/20 patients) and the clinical success rate was 90%(18/20 patients). Two patients(10%) who did not have complete sealing of the defect underwent surgery. Based upon our observations we propose two types of perforation: Round-shape "type-1 perforation" and oval-shape "type-2 perforation". Eight(40%) out of the 20 patients had a type-1 perforation and 12 patients a type-2(60%). CONCLUSION: OTSC placement should be attempted after perforation occurring during diagnostic or therapeutic endoscopy. A failed closure attempt does not impair subsequent surgical treatment.
文摘Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision(TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques(pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.
文摘Pancreatic vipoma is an extremely rare tumor accounting for less than 2% of endocrine pancreatic neoplasms with a reported incidence of 0.1-0.6 per million. While cross-sectional imaging findings are usually not specific, exact localization of the tumor by means of either computed tomography(CT) or magnetic resonance(MR) is pivotal for surgical planning. However, cross-sectional imaging findings are usually not specific and further characterization of the tumor may only be achieved bysomatostatin-receptor scintigraphy(SRS). We report the case of a 70 years old female with a two years history of watery diarrhoea who was found to have a solid, inhomogeneously enhancing lesion at the level of the pancreatic tail at Gadolinium-enhanced MR(Somatom Trio 3T, Siemens, Germany). The tumor had been prospectively overlooked at a contrast-enhanced multi-detector CT(Aquilion 64, Toshiba, Japan) performed after i.v. bolus injection of only 100 cc of iodinated non ionic contrast media because of a chronic renal failure(3.4 mg/mL) but it was subsequently confirmed by SRS. The patient first underwent a successful symptomatic treatment with somatostatin analogues and was then submitted to a distal pancreasectomy with splenectomy to remove a capsulated whitish tumor which turned out to be a well-differentiated vipoma at histological and immuno-histochemical analysis.
文摘Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),causing coronavirus disease 2019(COVID-19),can trigger autoimmunity in genetically predisposed individuals through hyperstimulation of immune response and molecular mimicry.Here we summarise the current knowledge about autoimmune liver diseases(AILDs)and SARS-CoV-2,focusing on:(1)The risk of SARS-CoV-2 infection and the course of COVID-19 in patients affected by AILDs;(2)the role of SARS-CoV-2 in inducing liver damage and triggering AILDs;and(3)the ability of vaccines against SARS-CoV-2 to induce autoimmune responses in the liver.Data derived from the literature suggest that patients with AILDs do not carry an increased risk of SARS-Cov-2 infection but may develop a more severe course of COVID-19 if on treatment with steroids or thiopurine.Although SARSCoV-2 infection can lead to the development of several autoimmune diseases,few reports correlate it to the appearance of de novo manifestation of immunemediated liver diseases such as autoimmune hepatitis(AIH),primary biliary cholangitis(PBC)or AIH/PBC overlap syndrome.Different case series of an AIHlike syndrome with a good prognosis after SARS-CoV-2 vaccination have been described.Although the causal link between SARS-CoV-2 vaccines and AIH cannot be definitively established,these reports suggest that this association could be more than coincidental.
文摘Staphylococcus aureus is an important zoonotic pathogen that is responsible for a variety of infectious diseases in humans and animals.The present study was designed to check the prevalence and antimicrobial resistance of MSSA from three different animal origins(bovine,caprine and pet).A total of n=450 samples(150 each source)were collected from bovine,caprine and pets.Collected samples were subjected to S.aureus identification by microbiological examination and confirmed S.aureus isolates were put to oxacillin disk diffusion test to declare them MSSA.The MSSA confirmed isolates were subjected to various antibiotics for susceptibility profiling using Kirby Bauer Disk Diffusion test.The present study found higher prevalence of MSSA from caprine origin(goat 83.33%)as compared to pet(cat 69.33%;dog 65.33%)and bovine origin(buffalo 26.66%;cattle 31.66%).The in-vitro findings of current study revealed oxytetracycline and gentamicin presented 100%efficacy against MSSA of all origins while the vancomycin presented>35%,>40%and>65%resistance against MSSA isolated from bovine,caprine and pet origin respectively.However,ciprofloxacin was equally effective(50%)against MSSA from buffalo and cattle while>80%efficacy was noted against MSSA from cat and dogs.Linezolid and amoxicillin+clavulanic acid were 77.78%and 66.67%sensitive to MSSA isolates from caprine milk.The present study found higher prevalence of MSSA from bovine,caprine and pet isolates with diversified pattern of susceptibility of different antibiotics from all sources.
文摘The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%,depending on the patient's age.Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones.At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include:single-stage laparoscopic treatment,perioperative endoscopic treatment and endoscopic treatment alone.Published data evidence that,associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay.However,current data does not suggest clear superiority of any one approach with regard to success,mortality,morbidity and cost-effectiveness.Considering the variety of therapeutic options available for management,a critical appraisal and decision-making is required.endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis,i.e.,in patients with acute obstructive suppurative cholangitis,severe biliary pancreatitis,ampullary stone impaction or severe comorbidity.In a setting where all facilities are available,decision in the selection of the therapeutic option depends on the patients,the number and size of choledocholithiasis stones,the anatomy of the cystic duct and common bile duct,the surgical history of patients and local expertise.
文摘The harmful use of alcohol is a worldwide problem.It has been estimated that alcohol abuse represents the world’s third largest risk factor for disease and disability;it is a causal factor of 60 types of diseases and injuries and a concurrent cause of at least 200 others.Liver is the main organ responsible for metabolizing ethanol,thus it has been considered for long time the major victim of the harmful use of alcohol.Ethanol and its bioactive products,acetaldehyde-acetate,fatty acid ethanol esters,ethanol-protein adducts,have been regarded as hepatotoxins that directly and indirectly exert their toxic effect on the liver.A similar mechanism has been postulated for the alcohol-related pancreatic damage.Alcohol and its metabolites directly injure acinar cells and elicit stellate cells to produce and deposit extracellular matrix thus triggering the"necrosis-fibrosis"sequence that finally leads to atrophy and fibrosis,morphological hallmarks of alcoholic chronic pancreatitis.Even if less attention has been paid to the upper and lower gastrointestinal tract,ethanol produces harmful effects by inducing:(1)direct damaging of the mucosa of the esophagus and stomach;(2)modification of thesphincterial pressure and impairment of motility;and(3)alteration of gastric acid output.In the intestine,ethanol can damage the intestinal mucosa directly or indirectly by altering the resident microflora and impairing the mucosal immune system.Notably,disruption of the intestinal mucosal barrier of the small and large intestine contribute to liver damage.This review summarizes the most clinically relevant alcohol-related diseases of the digestive tract focusing on the pathogenic mechanisms by which ethanol damages liver,pancreas and gastrointestinal tract.
文摘Endoscopic papillectomy(EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size(up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings(ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound(EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a "high-risk'' procedure due to complications. Complications of endoscopic papillectomy can be classified as early(pancreatitis, bleeding, perforation, and cholangitis) and late(papil-lary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis(FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.
文摘The present study was designed to alert the public opinion and policy makers on the supposed enhancing effects of exposure to ambient air particulate matter with aerodynamic diameters < 2.5 mm (PM 2.5 ) on non-alcoholic fatty liver disease (NAFLD), the most common chronic liver disease in Western countries. For far too long literature data have been fixated on pulmonary diseases and/or cardiovascular disease, as consequence of particulate exposure, ignoring the link between the explosion of obesity with related syndromes such as NAFLD and air pollution, the worst characteristics of nowadays civilization. In order to delineate a clear picture of this major health problem, further studies should investigate whether and at what extent cigarette smoking and exposure to ambient air PM 2.5 impact the natural history of patients with obesity-related NAFLD,i.e. , development of non alcoholic steatohepatitis, disease characterized by a worse prognosis due its progression towards fibrosis and hepatocarcinoma.
