Background: s/Aims: Postoperative pancreatic fistula (POPF) remains a significant complication following pancreatoduodenectomy (PD). It has been hypothesized that single loop (SL) reconstruction may increase the risk of POPF, leading to the proposal of double-loop (DL) reconstruction. In this approach, the pancreatic duct is connected to an isolated loop of bowel in a Roux-en-Y configuration. Methods: We conducted a retrospective multicenter study to compare various types of reconstruction after PD, analyzing data from 1,502 patients who underwent open, laparoscopic, or robotic PD across 28 centers worldwide. Propensity score matching (PSM) was applied to enhance comparability. Results: The overall rate of POPF was 34.89%, with a grade C POPF rate of 4.26%. The type of reconstruction (SL vs. DL) did not significantly impact the rates of POPF or grade C POPF, both before and after PSM. The rate of delayed gastric emptying (DGE) was 20.71%, and patients with DL reconstruction had a lower incidence of DGE both before and after PSM. Conclusions Our study found no significant differences in the risk of POPF between SL and DL reconstruction. However, DL reconstruction is associated with a reduced risk of DGE, suggesting it may be a preferable option following open PD.

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

Background: The aim of this meta-analysis was to synthesize the available evidence from the literature on the efficacy and safety of integrase inhibitor-based two drug regimens compared to triple drug regimens in virosuppressed people living with HIV (PLWH) in a long-term follow-up (at 96 weeks). Materials and Methods: A systematic review and meta-analysis were conducted to evaluate the efficacy, safety, and adverse drug reactions leading to discontinuation of two drug regimens compared to triple drug regimens in virosuppressed PLWH patients at 96 weeks of follow-up. We searched MEDLINE, Google Scholar, and the Cochrane Library up to March 15, 2024, and studies were selected for eligibility based on predefined criteria. Data were extracted independently by two reviewers, and risk ratios (RRs) were calculated as the measure of association between therapy and incidence of events. Results: Six studies were included in the analysis, both clinical trials and observational studies. The two drug regimens included cabotegravir/rilpivirine, dolutegravir/lamivudine, and dolutegravir/rilpivirine. No significant differences were observed in treatment failure (RR, 0.77; 95% confidence interval [CI], 0.53–1.13; P=0.182), virological failure (RR, 0.79; 95% CI, 0.48–1.29; P=0.341), adverse drug reactions leading to discontinuation (RR, 1.74; 95% CI, 0.73–4.17; P=0.215), or appearance of mutation (RR, 2.48; 95% CI, 0.33–18.68; P=0.379) between two drug regimen and triple drug regimen groups at 96 weeks of follow up. Conclusion The meta-analysis provide an overview of the available evidence and supports the use of two drug regimens as an option for simplifying treatment and improving clinical outcomes in virosuppressed PLWH.

Background: The aim of this meta-analysis was to synthesize the available evidence from the literature on the efficacy and safety of integrase inhibitor-based two drug regimens compared to triple drug regimens in virosuppressed people living with HIV (PLWH) in a long-term follow-up (at 96 weeks). Materials and Methods: A systematic review and meta-analysis were conducted to evaluate the efficacy, safety, and adverse drug reactions leading to discontinuation of two drug regimens compared to triple drug regimens in virosuppressed PLWH patients at 96 weeks of follow-up. We searched MEDLINE, Google Scholar, and the Cochrane Library up to March 15, 2024, and studies were selected for eligibility based on predefined criteria. Data were extracted independently by two reviewers, and risk ratios (RRs) were calculated as the measure of association between therapy and incidence of events. Results: Six studies were included in the analysis, both clinical trials and observational studies. The two drug regimens included cabotegravir/rilpivirine, dolutegravir/lamivudine, and dolutegravir/rilpivirine. No significant differences were observed in treatment failure (RR, 0.77; 95% confidence interval [CI], 0.53–1.13; P=0.182), virological failure (RR, 0.79; 95% CI, 0.48–1.29; P=0.341), adverse drug reactions leading to discontinuation (RR, 1.74; 95% CI, 0.73–4.17; P=0.215), or appearance of mutation (RR, 2.48; 95% CI, 0.33–18.68; P=0.379) between two drug regimen and triple drug regimen groups at 96 weeks of follow up. Conclusion The meta-analysis provide an overview of the available evidence and supports the use of two drug regimens as an option for simplifying treatment and improving clinical outcomes in virosuppressed PLWH.

Background: The aim of this meta-analysis was to synthesize the available evidence from the literature on the efficacy and safety of integrase inhibitor-based two drug regimens compared to triple drug regimens in virosuppressed people living with HIV (PLWH) in a long-term follow-up (at 96 weeks). Materials and Methods: A systematic review and meta-analysis were conducted to evaluate the efficacy, safety, and adverse drug reactions leading to discontinuation of two drug regimens compared to triple drug regimens in virosuppressed PLWH patients at 96 weeks of follow-up. We searched MEDLINE, Google Scholar, and the Cochrane Library up to March 15, 2024, and studies were selected for eligibility based on predefined criteria. Data were extracted independently by two reviewers, and risk ratios (RRs) were calculated as the measure of association between therapy and incidence of events. Results: Six studies were included in the analysis, both clinical trials and observational studies. The two drug regimens included cabotegravir/rilpivirine, dolutegravir/lamivudine, and dolutegravir/rilpivirine. No significant differences were observed in treatment failure (RR, 0.77; 95% confidence interval [CI], 0.53–1.13; P=0.182), virological failure (RR, 0.79; 95% CI, 0.48–1.29; P=0.341), adverse drug reactions leading to discontinuation (RR, 1.74; 95% CI, 0.73–4.17; P=0.215), or appearance of mutation (RR, 2.48; 95% CI, 0.33–18.68; P=0.379) between two drug regimen and triple drug regimen groups at 96 weeks of follow up. Conclusion The meta-analysis provide an overview of the available evidence and supports the use of two drug regimens as an option for simplifying treatment and improving clinical outcomes in virosuppressed PLWH.

Background/Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the go-to method for obtaining samples from gastrointestinal tract and pancreatic lesions. When the transduodenal approach is utilized, the use of a more flexible needle, such as a nitinol 19-gauge (G) needle, has been recommended. The aim of this study was to evaluate the feasibility and accuracy of 19-G flexible aspiration needles in obtaining samples from solid lesions through a transduodenal approach. Methods: This was a retrospective analysis of prospectively collected data from eight Italian endoscopy centers. Consecutive patients with solid lesions who underwent transduodenal EUS-FNA with a 19-G flexible needle were included. Results: A total of 201 patients were enrolled. According to histology, EUS, radiology and 12 months of follow-up, 151 patients had malignant lesions and 50 patients had benign lesions. EUS-FNA was feasible in all cases. An adequate histologic sample was obtained in all except eight cases (96.1%). The sensitivity of EUS-FNA was 92.1% (95% confidence interval [CI], 86.8%–95.7%), and the specificity was 100% (95% CI, 90.5%–100%). The positive predictive value was 100% (95% CI, 93.4%–100%), and the negative predictive value was 74% (95% CI, 62.8%–82.7%). The diagnostic accuracy was 93.5% (95% CI, 89.2%–96.5%). Conclusions The transduodenal approach for obtaining samples from solid lesions using a 19-G flexible needle seems feasible and accurate.

Background/Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the go-to method for obtaining samples from gastrointestinal tract and pancreatic lesions. When the transduodenal approach is utilized, the use of a more flexible needle, such as a nitinol 19-gauge (G) needle, has been recommended. The aim of this study was to evaluate the feasibility and accuracy of 19-G flexible aspiration needles in obtaining samples from solid lesions through a transduodenal approach. Methods: This was a retrospective analysis of prospectively collected data from eight Italian endoscopy centers. Consecutive patients with solid lesions who underwent transduodenal EUS-FNA with a 19-G flexible needle were included. Results: A total of 201 patients were enrolled. According to histology, EUS, radiology and 12 months of follow-up, 151 patients had malignant lesions and 50 patients had benign lesions. EUS-FNA was feasible in all cases. An adequate histologic sample was obtained in all except eight cases (96.1%). The sensitivity of EUS-FNA was 92.1% (95% confidence interval [CI], 86.8%–95.7%), and the specificity was 100% (95% CI, 90.5%–100%). The positive predictive value was 100% (95% CI, 93.4%–100%), and the negative predictive value was 74% (95% CI, 62.8%–82.7%). The diagnostic accuracy was 93.5% (95% CI, 89.2%–96.5%). Conclusions The transduodenal approach for obtaining samples from solid lesions using a 19-G flexible needle seems feasible and accurate.

Objective: Given that there are no studies on diseases that occur by waiting for hospitalization, we aimed to evaluate the main causes of death in the emergency room (ER) and their relationship with overcrowding. Methods: Patients who died in the ER in the past 2 years (pediatrics and trauma victims excluded) were divided into two groups: patients who died within 6 hours of arrival (emergency department [ED] group) and patients who died later (LD group). We compared the causes of death, total vital signs, diagnostic tests performed, and therapy between the groups. We assessed for possible correlation between the number of monthly deaths per group and four variables of overcrowding: number of patients treated per month, waiting time before medical visit (W-Time), mean intervention time (I-Time), and number of patients admitted to the ward per month (NPA). Results: During the two years, 175 patients had died in our ER (52% in ED group and 48% in LD group). The total time spent in the ER was, respectively, 2.9±0.2 hours for ED group and 17.9± 1.5 hours for LD group. The more frequent cause of death was cardiovascular syndrome (30%) in ED group and sepsis (27%) and acute respiratory failure (27%) in LD group. Positive correlations between number of monthly deaths and W-Time (R2 0.51, P<0.001), I-Time (R2 0.73, P< 0.0001), and NPA (R2 0.37, P<0.01) were found only in LD group. Conclusion Patients with sepsis and acute respiratory failure die after a long stay in the ER, and the risk increases with overcrowding. A fast-track pathway should be considered for hospital admission of critical patients.

The liver plays a crucial role in coagulation cascade. Global hemostatic process is profoundly influenced by the presence of liver disease and its complications. Patients with cirrhosis have impaired synthesis of most of the factors involved in coagulation and fibrinolysis process due to a reduced liver function and altered platelet count secondary to portal hypertension. Altered routine tests and thrombocytopenia were considered in the past as associated with increased risk of bleeding. These concepts explain both the routine use of plasma and/or platelets transfusion in patients with liver cirrhosis, especially before invasive procedures, and why these patients were considered “auto-anticoagulated”. New recent evidences show that patients with liver cirrhosis have a more complex hemostatic alteration. Despite the presence of altered levels of factors involved in primary hemostasis, coagulation and fibrinolysis, patients with stable cirrhosis have a rebalanced hemostatic, which however can easily be altered by decompensation or infection, both in hemorrhagic or thrombotic direction. Patients with cirrhosis have an increased risk of venous thrombotic events (namely portal vein thrombosis) while bleeding seems to be related to the grade of portal hypertension rather than to a hemostatic imbalance. The use of anticoagulants both as treatment or prophylaxis is safe, reduces the rate of portal vein thrombosis and decompensation, and improves survival. Standard laboratory coagulation tests are unable to predict bleeding and are inadequate for the assessment of hemostatic status in these patients, hence more comprehensive tests are required to guide the management of thrombotic and bleeding complications.
Anticoagulants ; Fibrinolysis ; Fibrosis* ; Hemorrhage ; Hemostasis ; Humans ; Hypertension, Portal ; Liver ; Liver Cirrhosis ; Liver Diseases ; Plasma ; Platelet Count ; Portal Vein ; Thrombocytopenia ; Venous Thrombosis

BACKGROUND/AIMS: Irritable bowel syndrome (IBS) is a multifactorial disorder, involving dysregulation of brain-gut axis. Our aim was to evaluate the neuroendocrine activity in IBS. METHODS: Thirty IBS and 30 healthy volunteers were enrolled. Psychological symptoms were evaluated by questionnaires. Urinary 5-hydroxyindoleacetic acid, plasma serotonin (5-hydroxytryptamine, 5-HT), endothelin, and neuropeptide Y (NPY), and plasma and urinary cortisol levels were evaluated. Fourteen IBS subjects underwent microneurography to obtain multiunit recordings of efferent postganglionic muscle sympathetic nerve activity (MSNA). RESULTS: Prevalent psychological symptoms in IBS were maladjustment (60%), trait (40%) and state (17%) anxiety, obsessive compulsive-disorders (23%), and depressive symptoms (23%). IBS showed increased NPY (31.9 [43.7] vs 14.8 [18.1] pmol/L, P = 0.006), 5-HT (214.9 [182.6] vs 141.0 [45.5] pg/mL, P = 0.010), and endothelin [1.1 [1.4] vs 2.1 [8.1] pg/mL, P = 0.054], compared to healthy volunteers. Moreover, plasma NPY, endothelin, cortisol and 5-HT, and urinary 5-hydroxyindoleacetic acid were associated with some psychological disorders (P ≤ 0.05). Despite a similar resting MSNA, after cold pressor test, IBS showed a blunted increase in MSNA burst frequency (+4.1 vs +7.8 bursts/min, P = 0.048; +30.1% vs +78.1%, P = 0.023). Baseline MSNA tended to be associated with urinary cortisol (ρ = 0.557, P = 0.059). Moreover, changes in heart rate after mental stress were associated with urinary cortisol (ρ = 0.682, P = 0.021) and changes in MSNA after mental stress were associated with plasma cortisol (ρ = 0.671, P = 0.024).” CONCLUSION: Higher concentrations of endothelin, NPY, and 5-HT were found to be associated with some psychological disorders in IBS patients together with an altered cardiovascular autonomic reactivity to acute stressors compared to healthy volunteers.
Anxiety ; Autonomic Nervous System ; Depression ; Endothelin-1 ; Endothelins ; Healthy Volunteers ; Heart Rate ; Humans ; Hydrocortisone ; Irritable Bowel Syndrome* ; Neuropeptide Y ; Pilot Projects* ; Plasma ; Serotonin