EUS-guided drainage using lumen apposing metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off necrosis: a case report and a review of the literature

Background: Endoscopic ultrasound-guided drainage is suggested as the first approach in the management of symptomatic and complex walled-off pancreatic necrosis. Dual approach with percutaneous drainage could be the best choice when the necrosis is deep extended till the pelvic paracolic gutter; however, the available catheter could not be large enough to drain solid necrosis neither to perform necrosectomy, entailing a higher need for surgery. Therefore, percutaneous endoscopic necrosectomy through a large bore percutaneous self-expandable metal stent has been proposed. Case presentation: In this study, we present the case of a 61-year-old man admitted to our hospital with a history of sepsis and persistent multiorgan failure secondary to walled-off pancreatic necrosis due to acute necrotizing pancreatitis. Firstly, the patient underwent transgastric endoscopic ultrasound-guided drainage using a lumen-apposing metal stent and three sessions of direct endoscopic necrosectomy. Because of recurrence of multiorgan failure and the presence of the necrosis deeper to the pelvic paracolic gutter at computed tomography scan, we decided to perform percutaneous endoscopic necrosectomy using an esophageal self-expandable metal stent. After four sessions of necrosectomy, the collection was resolved without complications. Therefore, we perform a revision of the literature, in order to provide the state-of-art on this technique. The available data are, to date, derived by case reports and case series, which showed high rates both of technical and clinical success. However, a not negligible rate of adverse events has been reported, mainly represented by fistulas and abdominal pain. Conclusion: Dual approach, using lumen apposing metal stent and percutaneous self-expandable metal stent, is a compelling option of treatment for patients affected by symptomatic, complex walled-off pancreatic necrosis, allowing to directly remove large amounts of necrosis avoiding surgery. Percutaneous endoscopic necrosectomy seems a promising technique that could be part of the step-up-approach, before emergency surgery. However, to date, it should be reserved in referral centers, where a multidisciplinary team is disposable

Predictive ability of the estimate of fat mass to detect early-onset metabolic syndrome in prepubertal children with obesity

Body mass index (BMI), usually used as a body fatness marker, does not accurately dis-criminate between amounts of lean and fat mass, crucial factors in determining metabolic syndrome (MS) risk. We assessed the predictive ability of the estimate of FM (eFM) calculated using the following formula: FM = weight − exp(0.3073 × height2 −10.0155×d-growth-standards/standards/body-mass-index-for-age-bmi-for-age weight−1 +0.004571×weight− 0.9180×ln(age) + 0.6488×age0.5 + 0.04723×male + 2.8055) (exp = exponential function, score 1 if child was of black (BA), south Asian (SA), other Asian (AO), or other (other) ethnic origin and score 0 if not, ln = natural logarithmic transformation, male = 1, female = 0), to detect MS in 185 prepubertal obese children compared to other adiposity parameters. The eFM, BMI, waist circumference (WC), body shape index (ABSI), tri-ponderal mass index, and conicity index (C-Index) were calculated. Patients were classified as hav-ing MS if they met ≥ 3/5 of the following criteria: WC ≥ 95th percentile; triglycerides ≥ 95th percen-tile; HDL-cholesterol ≤ 5th percentile; blood pressure ≥ 95th percentile; fasting blood glucose ≥ 100 mg/dL; and/or HOMA-IR ≥ 97.5th percentile. MS occurred in 18.9% of obese subjects (p < 0.001), with a higher prevalence in females vs. males (p = 0.005). The eFM was correlated with BMI, WC, ABSI, and Con-I (p < 0.001). Higher eFM values were present in the MS vs. non-MS group (p < 0.001); the eFM was higher in patients with hypertension and insulin resistance (p <0.01). The eFM shows a good predictive ability for MS. Additional to BMI, the identification of new parameters determi-nable with simple anthropometric measures and with a good ability for the early detection of MS, such as the eFM, may be useful in clinical practice, particularly when instrumentation to estimate the body composition is not available

Evaluation of Different Adiposity Indices and Association with Metabolic Syndrome Risk in Obese Children: Is there a Winner?

Body shape index (ABSI) and triponderal mass index (TMI) have been recently associated with cardiovascular risk in adults. A cross-sectional study was conducted to evaluate the relationship between different anthropometric adiposity indexes and metabolic syndrome (MetS) in Caucasian obese children and adolescents. Consecutive obese children aged 657 years have been enrolled. Anthropometric parameters, body composition (by bioelectrical impedance), and systolic and diastolic blood pressure have been measured. Fasting blood samples have been analyzed for lipids, insulin, glucose. A multivariate logistic regression analyses, with body mass index z-score, waist to height ratio, ABSI z-score, TMI, conicity index as predictors for MetS (IDEFICS and IDF criteria according to age) has been performed. Four hundred and three (179 boys and 224 girls) obese children, aged 7\u201320 years, have been evaluated. When we explored the joint contribution of each anthropometric and adiposity index of interest and BMIz on the risk of MetS, we found that the inclusion of ABSIz improved the prediction of MetS compared to BMIz alone. ABSI-BMI can be a useful index for evaluating the relative contribution of central obesity to cardiometabolic risk in clinical management of obese children and adolescents

INDICE DI ATEROGENICITA’ IN BAMBINI OBESI DOPO 1 ANNO DI INTERVENTO EDUCATIVO-NUTRIZIONALE BASATO SULLA DIETA MEDITERRANEA

Obiettivo: L’indice di aterogenicità plasmatica (AIP) riflette la relazione tra lipoproteine ad effetto protettivo e quelle aterogeniche. Lo studio intende valutare tale indice, che riflette il rischio cardiovascolare, in bambini obesi dopo 12 mesi di intervento educativo-nutrizionale. Metodi: Sono stati arruolati 125 bambini obesi di etnia caucasica. E’ stato calcolato lo z-score del BMI. Sono stati ottenuti campioni di sangue per la misurazione del profilo lipidico, dell’insulina e del glucosio, all’inizio (tempo T0) e al termine (tempo T1) dell’intervento nutrizionale. L’insulino-resistenza è stata valutata mediante l’indice HOMA-IR e l’indice TyG; la funzionalità delle cellule beta del pancreas e la sensibilità all’insulina mediante l’indice HOMA-B% e l’indice QUICKI, rispettivamente. Per il calcolo dell’AIP è stata utilizzata la seguente formula matematica: AIP= [Log(Trigliceridi/Colesterolo HDL)]. Si sono tenute sessioni educative per la promozione della dieta mediterranea associata all’attività fisica giornaliera. La significatività statistica della variazione longitudinale (T0-T1) è stata valutata mediante T-Test Per I Dati Appaiati (Wilcoxon-test). E’ stata effettuata l’analisi multivariata per l’influenza di età, sesso, stadio puberale di Tunner, valori di BMI z-score. Risultati: I bambini (n=118) a T1 hanno mostrato valori di BMI z-score più bassi rispetto a T0 [P50% dal valore di base è stata riscontrata in 38 bambini arruolati nello studio (32.2%). Conclusioni: L’AIP è stato per la prima volta considerato in uno studio pediatrico su bambini obesi ed è stata osservata una riduzione del suo valore dopo 12 mesi di intervento educativo-nutrizionale basata sui principi della dieta mediterranea

Nutritional, gastrointestinal and endo-metabolic challenges in the management of children with spinal muscular atrophy type 1

The management of patients with spinal muscular atrophy type 1 (SMA1) is constantly evolving. In just a few decades, the medical approach has switched from an exclusively palliative therapy to a targeted therapy, transforming the natural history of the disease, improving survival time and quality of life and creating new challenges and goals. Many nutritional problems, gastrointestinal disorders and metabolic and endocrine alterations are commonly identified in patients affected by SMA1 during childhood and adolescence. For this reason, a proper pediatric multidisciplinary approach is then required in the clinical care of these patients, with a specific focus on the prevention of most common complications. The purpose of this narrative review is to provide the clinician with a practical and usable tool about SMA1 patients care, through a comprehensive insight into the nutritional, gastroenterological, metabolic and endocrine management of SMA1. Considering the possible horizons opened thanks to new therapeutic frontiers, a nutritional and endo-metabolic surveillance is a crucial element to be considered for a proper clinical care of these patients