Enhanced recovery for liver transplantation: recommendations from the 2022 International Liver Transplantation Society consensus conference

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

What is the optimal antimicrobial prophylaxis to prevent postoperative infectious complications after liver transplantation? A systematic review of the literature and expert panel recommendations

BACKGROUND

Antimicrobial prophylaxis is well-accepted in the liver transplant (LT) setting. Nevertheless, optimal regimens to prevent bacterial, viral, and fungal infections are not defined.

OBJECTIVES

To identify the optimal antimicrobial prophylaxis to prevent post-LT bacterial, fungal, and cytomegalovirus (CMV) infections, to improve short-term outcomes, and to provide international expert panel recommendations.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel.

PROSPERO ID

CRD42021244976.

RESULTS

Of 1853 studies screened, 34 were included for this review. Bacterial, CMV, and fungal antimicrobial prophylaxis were evaluated separately. Pneumocystis jiroveccii pneumonia (PJP) antimicrobial prophylaxis was analyzed separately from other fungal infections. Overall, eight randomized controlled trials, 21 comparative studies, and five observational noncomparative studies were included.

CONCLUSIONS

Antimicrobial prophylaxis is recommended to prevent bacterial, CMV, and fungal infection to improve outcomes after LT. Universal antibiotic prophylaxis is recommended to prevent postoperative bacterial infections. The choice of antibiotics should be individualized and length of therapy should not exceed 24 hours (Quality of Evidence; Low | Grade of Recommendation; Strong). Both universal prophylaxis and preemptive therapy are strongly recommended for CMV prevention following LT. The choice of one or the other strategy will depend on individual program resources and experiences, as well as donor and recipient serostatus. (Quality of Evidence; Low | Grade of Recommendation; Strong). Antifungal prophylaxis is strongly recommended for LT recipients at high risk of developing invasive fungal infections. The drug of choice remains controversial. (Quality of Evidence; High | Grade of Recommendation; Strong). PJP prophylaxis is strongly recommended. Length of prophylaxis remains controversial. (Quality of Evidence; Very Low | Grade of Recommendation; Strong).

Loop-Mediated Isothermal Amplification of Trypanosoma cruzi DNA for Point-of-Care Follow-Up of Anti-Parasitic Treatment of Chagas Disease

A loop-mediated isothermal amplification assay was evaluated as a surrogate marker of treatment failure in Chagas disease (CD). A convenience series of 18 acute or reactivated CD patients who received anti-parasitic treatment with benznidazole was selected-namely, nine orally infected patients: three people living with HIV and CD reactivation, five chronic CD recipients with reactivation after organ transplantation and one seronegative recipient of a kidney and liver transplant from a CD donor. Fifty-four archival samples (venous blood treated with EDTA or guanidinium hydrochloride-EDTA buffer and cerebrospinal fluid) were extracted using a Spin-column manual kit and tested by T. cruzi Loopamp kit (Tc-LAMP, index test) and standardized real-time PCR (qPCR, comparator test). Of them, 23 samples were also extracted using a novel repurposed 3D printer designed for point-of-care DNA extraction (PrintrLab). The agreement between methods was estimated by Cohen's kappa index and Bland-Altman plot analysis. The T. cruzi Loopamp kit was as sensitive as qPCR for detecting parasite DNA in samples with parasite loads higher than 0.5 parasite equivalents/mL and infected with different discrete typing units. The agreement between qPCR and Tc-LAMP (Spin-column) or Tc-LAMP (PrintrLab) was excellent, with a mean difference of 0.02 [CI = -0.58-0.62] and -0.04 [CI = -0.45-0.37] and a Cohen's kappa coefficient of 0.78 [CI = 0.60-0.96] and 0.90 [CI = 0.71 to 1.00], respectively. These findings encourage prospective field studies to validate the use of LAMP as a surrogate marker of treatment failure in CD.

One stage percutaneous transhepatic biliary stenting for malignant jaundice: a safe, quick and economical option of treatment

OBJECTIVE

Patients with proximal malignant jaundices are often diagnosed in an advanced stage and need biliary decompression treatments, such as percutaneous transhepatic biliary drainage (PTBD) and bare metal stenting (BMS), to improve the hepatic function. Whether it is better to perform those two procedures together or in a separate time, it is not well understood. The aim of this study was to investigate the effectiveness and cost-benefit of a combined "one-stage" PTBD/BMS procedure in patients with malignant jaundices.

PATIENTS AND METHODS

Forty-five patients with malignant jaundice treated with "one-stage" PTBD/BMS were retrospectively enrolled to evaluate technical success, complications, survival, and length of hospitalization.

RESULTS

A full technical success of the procedures was reported for all patients, with only one major complication among 45 treated patients. A better performance in terms of hospitalization rate was achieved by the one-stage procedure compared to the two-stage, also resulting in global saving of costs. A high survival rate was observed at the 3rd and 6th month (97.7% and 86.6%, respectively), with a median overall survival time of 271,58 days.

CONCLUSIONS

Our study shows that performing PTBD/BMS as a "one-stage" procedure is useful, safe, and cost-effective with a high percentage of technical success and a similar occurrence of complications compared to the two-stage procedure.

Rectal indomethacin or intravenous gabexate mesylate as prophylaxis for acute pancreatitis post-endoscopic retrograde cholangiopancreatography

OBJECTIVE

We aimed to evaluate the results in our case series of AP ERCP over the last three years. The prophylaxis for acute pancreatitis (AP) post-endoscopic retrograde cholangiopancreatography (ERCP) consists of rectal indomethacin, but some studies are not concordant.

PATIENTS AND METHODS

We compared 241 ERCP performed from January 2014 to February 2015 with intravenous gabexate mesylate (Group A), with the 387 ERCP performed from March 2015 to December 2016 with rectal indomethacin (Group B) as prophylaxis for AP post-ERCP.

RESULTS

There were 8 (3.31%) AP post-ERCP in Group A vs. 4 (1.03%) in Group B.

CONCLUSIONS

Rectal indomethacin shows a better statistically significant performance than intravenous gabexate mesylate in the prophylaxis of AP post-ERCP, besides being cheaper.

Differential expression of multiple transglutaminases in human colon: impaired keratinocyte transglutaminase expression in ulcerative colitis

BACKGROUND AND AIMS

Ulcerative colitis (UC) is characterised by refractory inflammatory ulceration and damage to the colon. The mechanisms underlying impaired healing have yet to be defined. As transglutaminase expression resulting in matrix protein cross linking is associated with increased wound healing in a rat model of colitis, we hypothesised that different types of transglutaminase might also play a role in UC.

PATIENTS AND METHODS

Endoscopic and histological indices were studied in 26 patients with UC (10 active and 16 inactive) and in 20 normal controls undergoing colonoscopy. Transglutaminase activity was evaluated in plasma (factor XIIIa) by a radioenzymatic method. Factor XIIIa, tissue and keratinocyte transglutaminase protein content, and mRNA expression in the colon were evaluated by western blot analysis and semiquantitative reverse transcription-polymerase chain reaction (RT-PCR), respectively. Colonic location of transglutaminases and their reaction products, the epsilon-(gamma-glutamyl)lysine bonds, was evaluated by immunohistochemistry using specific monoclonal antibodies.

RESULTS

Transglutaminase activity was significantly lower in the plasma of patients with active UC (4.2 (2.4) mU/ml; p<0.05 v controls) than in those with inactive UC and controls (10.6 (2.2) and 12.1 (1.7) mU/ml). As shown by western blot, protein levels of tissue transglutaminase and factor XIIIa were unchanged in active UC compared with inactive disease and controls, while the keratinocyte form was reduced in active UC. Tissue transglutaminase and factor XIIIa immunostaining was strongly present in damaged areas colocalising with isopeptide bonds. In contrast, the keratinocyte form was almost absent in active UC and localised in the upper part of the crypts in normal subjects. RT-PCR showed upregulation of tissue transglutaminase mRNA in active UC (320% compared with controls) while keratinocyte transglutaminase gene expression was downregulated in active UC.

CONCLUSIONS

The results of the present study support the concept that, in the damaged colon, transglutaminases are needed in response to chronic injury and underline the key role of these enzymes in mucosal healing.

Helicobacter pylori strains and histologically-related lesions affect the outcome of triple eradication therapy: a study from southern Italy

BACKGROUND

Certain evidence suggests that Helicobacter pylori strains expressing genes for cytotoxin production show a higher sensitivity than non-cytotoxic organisms to eradication treatment. No data are available on the involvement of bacterium-related lesions in different therapeutic outcomes.

AIMS

(i) To investigate whether differences in eradication rates may be related to the different expression of virulent strains (cagA, vacA, iceA) in patients undergoing proton pump inhibitor-based triple therapy, and (ii) to evaluate whether therapeutic outcome may be affected by bacterium-induced gastric lesions.

METHODS

One hundred and ten H. pylori-positive subjects were enrolled. H. pylori was genotyped by polymerase chain reaction. Treatment consisted of lansoprazole-amoxicillin-clarithromycin, twice daily for 1 week. Eradication was checked by urea breath test.

RESULTS

The eradication rate was 70%, and the absence of cagA was associated with unsuccessful treatment. No difference between the groups with successful and unsuccessful eradication was found with regard to vacA and iceA. Lympho-epithelial lesions and fibrosis were associated with unsuccessful treatment.

CONCLUSIONS

The present data confirm the importance of cagA (but not vacA and iceA) as a predictor of successful eradication. When fibrosis and lympho-epithelial lesions are present, therapy appears to be less effective. Therefore, these histological features may be involved in an unsuccessful therapeutic outcome.

A comparative evaluation of gene transfer into blood cells using the same retroviral backbone for independent expression of the EGFP and deltaLNGFR marker genes

BACKGROUND AND OBJECTIVES

Retroviral vectors are widely used to deliver foreign genes to hematopoietic stem cells (HSC). Improvement of marking protocols needs reporter genes to allow rapid detection and efficient selection of transduced cells. The great potential of EGFP and LNGFR as reporter systems prompted us to compare them simultaneously, using the same retroviral backbone and the same gene transfer procedures.

DESIGN AND METHODS

The EGFP and LNGFR coding sequences were separately cloned into the MFG retroviral backbone. A cloning strategy assuring that both genes utilize the same ATG as the start codon was adopted. Marker gene expression, viral titers, transduction efficiency, and vector stability were evaluated in expanded amphotropic packaging clones and human hematopoietic cell lines by flow cytometry and PCR analysis. Vectors were also tested for their ability to transduce CD34+ peripheral blood cells.

RESULTS

A significantly larger number of MFG- LNGFR packaging clones were obtained that produced high viral titers. A direct correlation between viral titer and marker gene expression in packaging clones was demonstrated for both constructs. Similar expression kinetics and absence of in vitro toxicity in transduced cells were also observed for both constructs. Successful infection of CD34+ cells was achieved even after a short time of exposure to recombinant viruses.

INTERPRETATION AND CONCLUSIONS

Our results demonstrate that EGFP and LNGFR marker genes are equally useful for a rapid, specific and non-toxic detection of transduced cells. The MFG-EGFP construct appears useful to optimize gene transfer protocols in vitro. On the other hand, the MFG-LNGFR construct, for making possible a more efficient selection of high titer producer clones, as well as for safety and adaptability to the in vivo use, is more suitable for clinical applications.

Duodenogastric reflux, histology and cell proliferation of the gastric mucosa before and six months after cholecystectomy

In order to evaluate the effects that an increase in duodenogastric reflux (DGR) has on the mucosal cell proliferation of the non-operated stomach, we made a prospective study on 13 patients (9 female and 4 male, mean age 52 years) both before and 6 months after cholecystectomy, an operation which determines a significant increase in DGR with an intact pyloric sphincter. DGR was evaluated by measuring total intragastric bile acids (dosed by an enzymatic method), and single intragastric bile acids (dosed by High Performance Liquid Chromatography) and it was expressed as Fasting Bile Reflux (FBR) in mumol/h. Gastric cell proliferation was evaluated by measuring (by High Performance Liquid Chromatography) polyamine (putrescine, spermidine and spermine) levels in biopsy specimens taken from the antrum and gastric body. The histology of the antrum and gastric body was also evaluated. After cholecystectomy, there was a significant increase in DGR (delta = 39.23 mumol/h, 95% C.L. 11.69-136.22, sign-test for matched pairs p = 0.0003). The tissue concentration of putrescine in the antrum increased significantly (delta = 8.36 mumol/g of tissue, 95% C.L. 0.34-18.01, sign-test for matched pairs p = 0.013) and there was a worsening of histological findings in the antrum (preoperative chronic atrophic gastritis rate 38.5%, postoperative 69%). In the body there were no significant variations either in polyamine levels or in histology. The increase in DGR and in putrescine concentrations in the antrum were associated negatively (Spearman's rank -0.64, 95% C.L. -0.88 to -0.14).(ABSTRACT TRUNCATED AT 250 WORDS)

[Endoscopic aspects of primary non-Hodgkin's lymphoma of the stomach]

The introduction of endoscopy has led to a striking improvement in the diagnosis of primary non-Hodgkin gastric lymphomas due to the possibility of viewing the lesions directly and performing histological and cytological biopsies. Endoscopic findings are however polymorphous and may present difficulties of interpretation. The aim of this study was to re-examine the endoscopic data in 40 cases (25 M and 15 F) of gastric lymphoma observed during the period 1983-1990. There were three main endoscopic findings: ulcerated lesions (55%), infiltrating lesions (40%) and polypoid lesions (5%). In 75% of cases the biopsies carried out during the course of endoscopic examination were positive for lymphoma; in 7.5% of cases histological diagnosis was made using macrobiopsies carried out using a diathermic loop whereas in 17.5% it was made during the course of laparotomy. It may be possible to make further progress towards an early diagnosis following the introduction of echoendoscopy which will allow an in-depth evaluation of lesions and the involvement of lymph node stations and nearby organs.

Duodenogastric reflux and gastric histology after cholecystectomy with or without sphincteroplasty

Sixteen patients who had undergone cholecystectomy plus sphincteroplasty, 14 cholecystectomized patients and ten control patients were studied to evaluate whether differences existed in duodenogastric reflux and whether these were related to morphological damage of the gastric mucosa. Duodenogastric bile reflux during fasting was evaluated by measuring the concentration of total bile acids (by an enzymatic method) and single bile acids in the gastric juice by high performance liquid chromatography. The damage was evaluated histologically by systematic endoscopic biopsy of the antrum and body of the stomach. There was a statistically significant difference in fasting bile reflux between the three groups (Kruskal-Wallis test, P less than 0.001), and the group that underwent cholecystectomy plus sphincteroplasty had a significantly higher median value than the cholecystectomized group (P less than 0.05) and the control group (P less than 0.01). The distribution of chronic antral atrophic and superficial gastritis was different in the three groups (chi 2 test, P less than 0.005). Chronic atrophic gastritis was associated with cholecystectomy plus sphincteroplasty (P less than 0.01), while chronic superficial gastritis was more frequent in cholecystectomized patients. These results suggest that there may be more duodenogastric reflux after cholecystectomy plus sphincteroplasty than after cholecystectomy alone, and that there may be a correlation between the amount of duodenogastric reflux and the severity of mucosal damage.

[Emergency endoscopy in upper gastrointestinal hemorrhage]

The paper reports a series of 236 patients who underwent emergency esophagogastroduodenoscopy (EGDS) (within 48 hours of hospitalisation) due to hemorrhage of the upper digestive tract. A definitive diagnosis of the of bleeding was made in 233 (98.7%) cases. In 1.3% of cases, endoscopic tests proved negative. The most frequent cause of bleeding was duodenal ulcer, followed by esophageal varices. Hemorrhage was caused in only 46.2% of 80 cirrhotic patients by the rupture of esophageal varices, whereas in the remaining 53.8% of cases the source of hemorrhage was a lesion associated to esophageal varices. Surgery was necessary in 15 patients (6.4%). The death rate within 30 days was 5.5%. In conclusion, emergency EGDS performed within 24 hours of hospitalisation is the most precise diagnostic technique for upper gastrointestinal bleeding.

[Prevention of duodenal ulcer recurrence by the use of anti H2. Comparison of continuous long-term and seasonal therapy]

The Authors have assessed the incidence of ulcer recidivation in patients with cicatrized bulbar ulcers following anti H2 treatment using two maintenance therapy protocols: 1) 400 mg/day of cimetidine in a single evening dose for 1 year (continuous therapy); 2) the same dose of cimetidine administered at the same time but only for 4 months a year (February-March and September-October) (seasonal therapy). Ninety patients with cicatrized ulcers which had been diagnosed using endoscopy were randomly assigned to the two treatment protocols. Protocols were followed for a least one year with endoscopic controls every 6 months. There were no significant differences between continuous and seasonal therapy in relation to the recurrence of duodenal ulcers (Log Rank test p less than 0.05). Cox's proportional hazard model was used to assess the effect of the two treatment protocols on ulcer recurrence eliminating the influence of sex, age and smoking; it was seen that only smoking influenced the incidence of recidivation (p less than 0.05). These results suggest that seasonal maintenance therapy with anti H2 is as efficacious as continuous therapy in preventing the recurrence of ulcers.

Duodenogastric reflux of bile acids, gastrin and parietal cells, and gastric acid secretion before and 6 months after cholecystectomy

In order to evaluate the effect of cholecystectomy on the gastric mucosa, the duodenogastric reflux of total and single bile acids, the number of parietal and gastrin cells, and the volume of gastric acid secretion were examined in 15 patients with gallstones and functioning gallbladders before and 6 months after cholecystectomy. The duodenogastric reflux of the total bile acids increased from a mean preoperative value of 1.9 mumol/hour to a mean postoperative value of 21 mumol/hour (p = 0.008). The duodenogastric reflux of all single bile acids increased after cholecystectomy, with a higher increase in glycoconjugated compared with tauroconjugated bile acids. The parietal cells decreased from a mean preoperative value of 82.8 to a mean postoperative value of 68.7 (p = 0.05), whereas there was only a mild increase in the number of gastrin cells; the output of gastric acid remained unchanged. The variation of the gastrin cells before and after cholecystectomy was negatively correlated only with the variation of taurocholic acid (r = -0.50, p = 0.05), while the variation of the parietal cells was mildly correlated with all single bile acids (r = 0.35-0.50, 0.05 less than p less than 0.02). These findings show an increased duodenogastric reflux of bile acids 6 months after cholecystectomy with a mild morphologic alteration of the gastric mucosa.

[The role of emergency colonoscopy in colorectal hemorrhage]

The diagnosis of lower intestinal hemorrhage usually follows the successive sequence: a) digital rectal examination, b) rectosigmoidoscopy, c) barium enema, d) colonoscopy. This latter method has proven to be the most sensitive. This study is a retrospective examination of the results obtained by emergency colonoscopy on the diagnosis and treatment of lower intestinal hemorrhage. Out of 1258 colonoscopy procedures performed between January 1983 and June 1988 in the Digestive Endoscopy Unit of our Institute, 44 (3.5%) were emergency procedures (within 48 hrs. after recovery) due to lower intestinal hemorrhage. The most frequent causes of hemorrhage found were the following: 1) hemorrhagic colitis (20.5%), 2) polyps (13.6%), 3) hemorrhoids (13.6%), 4) carcinoma (9.0%). The hemorrhagic source was not established in 9 cases (20.5%). The sensitivity of this method was therefore 97.2%. In 6 cases of hemorrhagic polyps treatment to stop bleeding was also possible by means of the colonoscopy (endoscopic polypectomy). In our experience, the emergency colonoscopy was found to be a highly sensitive diagnostic procedure for lower intestinal hemorrhages, permitting even definitive treatment of the lesion in 13.6% of cases with no complications associated with the technique. We feel therefore that, when available, it should be considered the first and foremost exam to be performed for emergency diagnosis of colo-rectal hemorrhages.

[Intragastric pH determination as a screening test in the diagnosis of chronic atrophic gastritis]

A simple routine endoscopic screening test has been sought for the diagnosis of chronic atrophic gastritis. An endoscopic-bioptic study was therefore carried out on 850 subjects presenting consecutively at a Digestive Endoscopy Department with dyspeptic-pain symptomatology. In a first sample of 389 patients, 2 biopsies of the gastric body and 2 of the gastric antrum were carried out, independently of the endoscopically documented macroscopic picture. Atrophic changes were in this way encountered in 65 patients (16.7%). In a second group of 461 patients, intragastric pH was determined extemporaneously during endoscopy. pH was = or greater than the chosen threshold value (3.5) in 117 patients and less than this value in 344. In all subjects with pH greater than 3.5 and, by comparison, in 130 with pH less than 3.5 biopsy was carried out on the gastric mucosa, 2 biopsies of the body and 2 of the antrum. Using this approach it was possible to determine the presence of atrophic changes in the gastric mucosa in 57 of 117 (48%) and in 25 of 130 (20%) respectively. In total, chronic atrophic gastritis was diagnosed in 83 of 461 subjects (18%). This percentage is comparable to that observed in the frequency of chronic atrophic gastritis using the more demanding and less selective test of bioptic sampling indiscriminately for all patient. So, the straight-forward determination of intragastric pH in a sample of gastric juice taken during digestive endoscopy would appear to meet the criteria demanded for a screening test and its wider use is recommended in routine endoscopic practice.

[Cholecystectomy and adenomatous polyps of the colorectum]

The possible correlation between cholecystectomy and adenomatous polyps of the colorectum is evaluated by means of a retrospective study of 2 groups of patients: 90 patients subjected to endoscopic removal of one or more adenomatous polyps of the colon-rectum (histological diagnosis) and 90 control patients paired by sex and age, hospitalised for benign pathology and selected from among those submitted to totally negative colonoscopy. Ten patients (11.1%) were submitted to cholecystectomy among those with adenomatous polyps, 5 (5.5%) in the control group. Subdividing patients by sex women evidenced a relative risk of 5 (O.R. = 5/1, degree of confidence 95% = 0.7-33.4) but the figure was not statistically significant. For males, on the other hand, the relative risk was 1 (O.R. = 5/4). It is concluded that cholecystectomy may be considered a risk factor for the development of adenomas of the colon-rectum in females.

[Adenoma-carcinoma sequence in the right colon]

Most endoscopically treated colorectal adenomas are found in the sigmoid colon and the incidence gradually diminishes in the proximal districts until we reach a figure of 10% or so in the right colon. The present series of 356 adenomas endoscopically removed in 1980-85 differs from other reports in that 24.4% of the adenomas were located in the right colon. These 87 adenomas were mostly (79%) under 5 mm in diameter, sessile (89%) and histologically tubular with slight dysplasia (95%). Only 3 adenomas over 10 mm in diameter and tubulovillous presented severe dysplasia. This high incidence of right colonic adenomas differs significantly from findings in other endoscopic series but is in line with the findings of an autoptic study of colorectal polyps (21% of the adenomas were found in the right colon). In addition both in the autoptic study and the present endoscopic series the adenomas of the right colon were small, only slightly dysplastic, unlikely to evolve into malignancy and could have been created by the E1 factor hypothesised by Hill et al. These data confirm the low incidence of right colonic cancer and suggest that patients subjected to the removal of small adenomas of the right colon do not require close surveillance.

New phenotypic aspects in a family with Lynch syndrome II

Increasing attention has been given to hereditary nonpolyposis colorectal cancer (HNPCC). This report provides medical genetic/pathologic findings on an HNPCC kindred from southern Italy that shows criteria consistent with Lynch syndrome II. An international collaborative effort led to extension of this kindred with disclosure of a potentially new spectrum of phenotypic findings: an excess of gastric carcinoma; complete intestinal metaplasia and chronic atrophic gastritis restricted to the antrum; an apparent excess of colonic mucosal macrophagia, which by special stain appeared to be positive for mucin, with a constant content of both sialo and sulfomucin, a lack of iron, and an inconstant positivity for lysozyme obtained by immunoperoxidase technique; and findings of crypt atrophy of the colonic mucosa. During the relatively short period of investigation of this family, an intensive educational and surveillance program has been mounted in the interest of improving cancer control through direct application of knowledge of natural history and the risk factor evidence through pedigree assessment.

New phenotypic aspects in a family with Lynch syndrome II

Increasing attention has been given to hereditary nonpolyposis colorectal cancer (HNPCC). This report provides medical genetic/pathologic findings on an HNPCC kindred from southern Italy that shows criteria consistent with Lynch syndrome II. An international collaborative effort led to extension of this kindred with disclosure of a potentially new spectrum of phenotypic findings: an excess of gastric carcinoma; complete intestinal metaplasia and chronic atrophic gastritis restricted to the antrum; an apparent excess of colonic mucosal macrophagia, which by special stain appeared to be positive for mucin, with a constant content of both sialo and sulfomucin, a lack of iron, and an inconstant positivity for lysozyme obtained by immunoperoxidase technique; and findings of crypt atrophy of the colonic mucosa. During the relatively short period of investigation of this family, an intensive educational and surveillance program has been mounted in the interest of improving cancer control through direct application of knowledge of natural history and the risk factor evidence through pedigree assessment.