News & Views in 2011

Despite numerous trials, the question of whether to use ciclosporin or tacrolimus treatment following liver transplantation in patients with HCV infection is still unresolved. A large retrospective analysis now indicates that tacrolimus is preferable; however, several limitations of this study must be considered.

The incidence of nonalcoholic fatty liver disease (NAFLD) in children is growing in parallel with that of obesity; however, to date, no drugs have been approved for its treatment. Results from a 5-year clinical trial show that neither metformin nor vitamin E are effective for the treatment of pediatric NAFLD.

Conservative treatment of high-output postoperative pancreatic fistulas (POPFs) includes prolonged fasting with nutritional support. However, the choice between enteral and parenteral nutrition is arbitrary. A randomized clinical trial that compared these two types of nutritional support has demonstrated that enteral feeding is associated with a substantially higher closure rate and a shorter time to closure of POPFs.

A recent position paper by the American Gastroenterological Association has made a range of excellent recommendations for the management of patients with Barrett esophagus. However, the guidelines have several important limitations, including the omission of endoscopic therapy for patients who have T1 Barrett adenocarcinoma.

The failure of antiviral therapy for chronic hepatitis B can involve both virological breakthrough and genotypic resistance. A study of the failure of nucleoside analogue therapy suggests that drug-resistant mutants are not solely responsible for treatment failure. Suboptimal treatment adherence might also have an important role.

Despite major advances in understanding its prevention and treatment, diarrhea remains a leading cause of global child deaths and a potentially important cause of lifelong morbidity. A new study asks the question: how many lives would be saved by universal scaling up of best practices for diarrhea prevention and control?

Owing to the shortage of donor organs, improved selection criteria are needed for allocating patients with hepatocellular carcinoma (HCC) to receive orthotopic liver transplantation (OLT). A study has found that the neutrophil:lymphocyte ratio independently predicts tumor recurrence after OLT for HCC and, therefore, might constitute a simple entry criterion that measures host inflammation status.

Currently, there is no satisfactory treatment for patients coinfected with hepatitis B virus and hepatitis D virus, which causes hepatitis D—the most severe form of hepatitis. A recent study has assessed the safety and efficacy of PEG-IFN-α2a and adefovir alone and in combination in these patients.

Constipation is a very common condition that is frequently managed suboptimally. A recent single-blind, randomized, crossover study has reported the superior effects of dried plums (prunes) over the stool-bulking fiber supplement psyllium in the treatment of mild to moderate symptoms of constipation.

Increasing clarithromycin resistance is dramatically reducing the efficacy of standard triple therapy for Helicobacter pylori eradication. Quadruple therapy is associated with high cure rates, yet its complex administration protocol hampers its acceptability for general use. A recent study has assessed the efficacy and safety of a novel, single-capsule bismuth-containing quadruple therapy.

Up to 30% of patients with refractory ulcerative colitis have steroid-resistant disease and, if cured with restorative proctocolectomy, could develop pouchitis. Ciclosporin and infliximab monotherapy have been used experimentally to tackle this problem. A recent study has assessed ciclosporin and infliximab as second-line therapies when one has failed.

Combination therapy for chronic hepatitis C is associated with adverse effects that can lead to dose reduction or even discontinuation of treatment. A prospective, real-time, observational study by Marcellin and colleagues provides useful information for physicians regarding the role of patient adherence in tailoring patient management and optimizing treatment outcomes.

Although endoscopic retrograde cholangiopancreatography (ERCP) is a well-established technique for both the diagnosis and treatment of biliary and pancreatic disorders in adults, indications for some pediatric applications, such as idiopathic and recurrent pancreatitis, remain contentious. This News & Views article discusses a recent study that evaluated the technical outcomes and safety of 231 ERCPs in children.

A new staging system for perihilar cholangiocarcinoma has recently been proposed to standardize the reporting of this intractable disease. However, the system has several flaws; thus, many revisions are needed before a registry can be established that uses this system.

Most children with chronic hepatitis C have minimal liver disease before adulthood, but could be at risk of progression to cirrhosis and hepatocellular carcinoma because of persistent virus replication. The results of the first controlled trial with PEG-IFN-α2a plus ribavirin are a step towards an appropriate treatment for these children.

Minimizing donor risks during living donor liver transplantation is important. A recent study recommends that a right lobe graft with the middle hepatic vein is obtained from donors <50 years old who have an intact segment four drainage vein and remnant liver volume >30%.

An international consortium (the Colon Cancer Family Registry) has recently published interesting data on the risk of developing metachronous colorectal cancer (CRC) after treatment of primary CRC in patients with Lynch syndrome. The findings are clinically important as they might justify more extensive surgery to treat primary CRC in these patients.

Antibodies that target tumor necrosis factor are effective at inducing and maintaining remission in both Crohn's disease (infliximab, adalimumab and certolizumab) and ulcerative colitis (infliximab). The results of a randomized controlled trial of adalimumab for inducing remission in moderately to severely active ulcerative colitis have now been published.

Both stepwise radical endoscopic resection (SRER) and radiofrequency ablation (RFA) are effective endoscopic strategies for the treatment of patients with flat, dysplastic Barrett esophagus. Findings from a randomized, controlled trial indicate that the two treatments have similar efficacy, but considerably more complications are associated with SRER compared with RFA.

The issue of propofol administration by nonanesthesiologists for upper endoscopy and colonoscopy remains controversial. A recent study investigated the efficacy and safety of a novel computer-assisted personalized sedation device. Patients sedated using the device experienced fewer serious cardiorespiratory events than patients undergoing standard sedation by bolus administration using a hand-held syringe.