Endoscopic features with associated histological and molecular alterations in serrated polyps with dysplasia: Retrospective analysis of a tertiary case series

BACKGROUND

Serrated polyps are incompletely understood lesions and include serrated sessile lesion (SSL) without or with dysplasia and traditional serrated adenoma (TSA).

AIMS

We investigated prevalence and characteristics of serrated lesions, especially SSL with dysplasia (mixed polyps).

METHODS

This retrospective study analyzed data from consecutive patients referred for colonoscopy at a tertiary care center. Endoscopic and histopathological characteristics of identified lesions were studied. SSLs with dysplasia were molecularly analyzed for mutations and microsatellite instability.

RESULTS

Among 1147 patients, a total of 436 polyps were found, including 288 adenomas (66.1 %) and 114 serrated lesions (SLDR 26.2 %). PDR was 34.5 % and ADR was of 30.2 %. Serrated lesions included 75 hyperplastic polyps (17.2 %), 24 SSLs without dysplasia (5.5 %), 6 SSLs with dysplasia (mixed polyps) (1.4 %) and 9 TSA (2.1 %). The mixed polyps were evaluated molecularly: these analyses found no KRAS mutation, a single NRAS mutation in one lesion, the Val600Glu BRAF mutation in four lesions in both their serrated non-dysplastic and dysplastic areas, and microsatellite instability in four lesions, limited to the dysplastic areas.

CONCLUSION

Our single-center experience confirms the high prevalence of serrated lesions, a part of which are SSL with dysplasia. These lesions seem to carry specific molecular alterations.

SIED-GISCOR recommendations for colonoscopy in screening programs: Part I - Diagnostic

The implementation of FIT programs reduces incidence and mortality from CRC in the screened subjects. The ultimate efficacy for CRC morbidity and mortality prevention in a FIT program depends on the colonoscopy in FIT+ subjects that has the task of detecting and removing these advanced lesions. Recently, there has been growing evidence on factors that influence the quality of colonoscopy specifically withing organized FIT programs, prompting to dedicated interventions in order to maximize the benefit/harm ratio of post-FIT colonoscopy. This document focuses on the diagnostic phase of colonoscopy, providing indications on how to standardise colonoscopy in FIT+ subjects, regarding timing of examination, management of antithrombotic therapy, bowel preparation, competence and sedation.

Standard Bismuth Quadruple Therapy versus Concomitant Therapy for the First-Line Treatment of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

(1) Background: Whether standard bismuth quadruple therapy (BQT) is superior to concomitant therapy for the first-line treatment of Helicobacter (H.) pylori infection is unclear. The aim of this systematic review and meta-analysis was to compare the efficacy of standard BQT versus concomitant therapy for H. pylori eradication in subjects naïve to treatment. (2) Methods: Online databases were searched for randomized controlled trials. We pooled risk ratio (RR) of individual studies for dichotomous outcomes using a random-effect model. (3) Results: Six studies with 1810 adults were included. Overall intention-to-treat (ITT) eradication rate was 87.4% with BQT and 85.2% with concomitant therapy (RR 1.01, 95%CI:0.94-1.07). Subgroup analysis of five Asian studies showed a small but significant superiority of BQT over concomitant therapy (87.5% vs. 84.5%; RR 1.04, 95%CI:1.01-1.08). Pooling four studies at low risk of bias yielded a similar result (88.2% vs. 84.5%; RR 1.05, 95%CI:1.01-1.09). There was no difference between the regimens in the frequency of adverse events (RR = 0.97, 95%CI:0.79-1.2). (4) Conclusions: The efficacy of BQT seems to be similar to concomitant therapy, with similar side effect profile. However, BQT showed a small but significant benefit over concomitant therapy in Asian populations and in studies at low risk of bias.

Over-the-scope Technique for Partially Covered Self-expandable Metal Stent Placement to Treat Duodenal Perforation during EUS

BACKGROUND AND AIMS

Although endoscopic ultrasound (EUS) is generally safe, duodenal perforation may occur during the procedure. When the iatrogenic break is wide, endoscopic positioning of a covered self- expandable metal stent is indicated to avoid a more invasive surgical approach. We evaluated the efficacy of the 'over-the-scope stenting' (OTSS) technique to treat iatrogenic duodenal perforations occurred during EUS.

METHODS

Data of patients with large iatrogenic duodenal perforations treated with OTSS procedure were collected in 5 centers. Technical success was defined as a correct stent placement on the perforation site, and clinical success as complete healing of the duodenal leak at stent removal 3 weeks later.

RESULTS

A total of 15 (7 males; median age: 78 years, range 47-91) patients were included in this series. A correct stent positioning was achieved in all cases (technical success: 100%), and the perforation was healed in all, apart from one patient at stent removal (clinical success: 93%). This patient was successfully treated with a novel stent placement. No immediate post-procedural adverse events occurred, and no need for emergency surgery was recorded. In one (6.7%) patient, stent migration occurred 10 days after positioning, and it was spontaneously expulsed with stool movement without complications two days later.

CONCLUSIONS

Our data showed that the OTTS technique for partially covered self-expandable metal stent placement is feasible, safe and effective to tread large iatrogenic duodenal perforation occuring during EUS.

Endoscopic Submucosal Dissection for Subepithelial Tumor Treatment in the Upper Digestive Tract: A Western, Multicenter Study

<b><i>Background/Aims:</i></b> Endoscopic submucosal dissection (ESD) has been proposed for removal of gastrointestinal subepithelial tumors (GI-SETs), but data are still scanty. This study aimed to report a case series from a western country. <b><i>Patients and Methods:</i></b> Data of patients with upper GI-SETs suitable for ESD removal observed in 4 centers were retrospectively reviewed. Before endoscopic procedure, the lesion was characterized by endosonographic evaluation, histology, and CT scan. The <i>en bloc</i> resection and the R0 resection rates were calculated, as well as incidence of complications, and the 1-year follow-up was reported. <b><i>Results:</i></b> Data of 84 patients with esophageal (<i>N</i> = 13), gastric (<i>N</i> = 61), and duodenal (<i>N</i> = 10) GI-SETs were collected. The mean diameter of lesions was 26 mm (range: 12–110 mm). There were 17 gastrointestinal stromal tumors, 12 neuroendocrine tumors, 35 leiomyomas, 18 lipomas, and 2 hamartomas. <i>En bloc</i> and R0 resection were achieved in 83 (98.8%) and in 80 (95.2%) patients, respectively. Overall, a complication occurred in 11 (13.1%) patients, including bleeding (<i>N</i> = 7) and perforation (<i>N</i> = 4). Endoscopic approach was successful in all bleedings, but 1 patient who required radiological embolization, and in 2 perforations, while surgery was performed in the other patients. Overall, a surgical approach was eventually needed in 5 (5.9%), including 3 in whom R0 resection failed and 2 with perforation. <b><i>Conclusions:</i></b> Our study found that ESD may be an effective and safe alternative to surgical intervention for both benign and localized malignant GI-SETs.

Endoscopic clipping in non-variceal upper gastrointestinal bleeding treatment

Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions.

New endoscopic capsule vs upper gastrointestinal endoscopy in preoperative work-up of obese candidate for bariatric surgery: Relevance of a pilot study in the COVID-19 era

Background and study aims  Obesity represents a major health concern; bariatric surgery is the most effective treatment reducing and maintaining weight loss. The role of a routine esophagogastroduodenoscopy (EGD) prior bariatric surgery is still debated. Moreover, in this scenario of COVID-19 pandemic, EGD is even more questionable due to the procedural risk of viral transmission. A new model of video-endoscopic capsule (VEC) recently has been introduced as a good alternative to the EGD. The aim of this study was to determine if this new capsule is an adequate diagnostic alternative to EGD in the work-up of patients selected for bariatric surgery, particularly in the setting of COVID-19. Patients and methods  From January to November 2020, 27 patients selected for bariatric surgery were enrolled in this pilot study to assess for noninferiority of VEC compared to EGD in detection of upper gastrointestinal disease. Results  VEC had sensitivity, specificity, and positive and negative predictive values in identification of significant lesions of 91.3 %, 83.33 %, 98.01 %, and 51.57 %, respectively, compared with EGD as the standard criterion. The accuracy was 90.51 % (95 % CI, 73.75 %-98.18 %) and the chi-square statistic is 0.1153 ( P  = 0.73). Conclusions  Our report confirms the diagnostic noninferiority of VEC in preoperative work-up of patients selected for bariatric surgery, compared to EGD. This is very important, particularly during the COVID-19 pandemic, given the high risk of contamination with EGD. Larger multicenter studies are required to confirm our preliminary results.

Endorectal Ultrasonography and Pelvic Magnetic Resonance Imaging Show Similar Diagnostic Accuracy in Local Staging of Rectal Cancer: An Update Systematic Review and Meta-Analysis

Background: Endorectal Ultrasonography (EUS-ERUS) and pelvic magnetic resonance imaging (MRI) are world-wide performed for the local staging of rectal cancer (RC), but no clear consensus on their indications is present, there being literature in support of both. The aim of this meta-analysis is to give an update regarding the diagnostic test accuracy of ERUS and pelvic MRI about the local staging of RC. Materials and methods: A systematic literature search from November 2020 to October 2021 was performed to select studies in which head-to-head comparison between ERUS and MRI was reported for the local staging of rectal cancer. Quality and risk of bias were assessed with the QUADAS-2 tool. Our primary outcome was the T staging accuracy of ERUS and MRI for which pooled accuracy indices were calculated using a bivariable random-effects model. In addition, a hierarchical summary receiver operating characteristic curve (hSROC) was created to characterize the accuracy of ERUS and MRI for the staging of T and N parameters. The area under the hSROC curve (AUC_hSROC) was determined as a measure of diagnostic accuracy. Results: Seven studies and 331 patients were included in our analysis. ERUS and MRI showed a similar accuracy for the T staging, with AUC_hSROC curves of 0.91 (95% C.I., 0.89 to 0.93) and 0.87 (95% C.I., 0.84 to 0.89), respectively (p = 0.409). For T staging, ERUS showed a pooled sensitivity of 0.82 (95% C.I. 0.72 to 0.89) and pooled specificity of 0.91 (95% C.I. 0.77–0.96), while MRI had pooled sensitivity and specificity of 0.69 (95% C.I. 0.55–0.81) and 0.88 (95% C.I. 0.79–0.93), respectively. ERUS and MRI showed a similar accuracy in the N staging too, with AUC_hSROC curves of 0.92 (95% C.I., 0.89 to 0.94) and 0.93 (95% C.I., 0.90 to 0.95), respectively (p = 0.389). Conclusions: In conclusion, ERUS and MRI are comparable imaging techniques for the local staging of rectal cancer.

Attending Training Courses on Barrett's Esophagus Improves Adherence to Guidelines: A Survey from the Italian Society of Digestive Endoscopy

BACKGROUND

Little is known on practice patterns of endoscopists for the management of Barrett's esophagus (BE) over the last decade.

AIMS

Our aim was to assess practice patterns of endoscopists for the diagnosis, surveillance and treatment of BE.

METHODS

All members of the Italian Society of Digestive Endoscopy (SIED) were invited to participate to a questionnaire-based survey. The questionnaire included questions on demographic and professional characteristics, and on diagnosis and management strategies for BE.

RESULTS

Of the 883 SIED members, 259 (31.1%) completed the questionnaire. Of these, 73% were males, 42.9% had > 50 years of age and 68.7% practiced in community hospitals. The majority (82.9%) of participants stated to use the Prague classification; however 34.5% did not use the top of gastric folds to identify the gastro-esophageal junction (GEJ); only 51.4% used advanced endoscopy imaging routinely. Almost all respondents practiced endoscopic surveillance for non-dysplastic BE, but 43.7% performed eradication in selected cases and 30% practiced surveillance every 1-2 years. The majority of endoscopists managed low-grade dysplasia with surveillance (79.1%) and high-grade dysplasia with ablation (77.1%). Attending a training course on BE in the previous 5 years was significantly associated with the use of the Prague classification (OR 4.8, 95% CI 1.9-12.1), the top of gastric folds as landmark for the GEJ (OR 2.45, 95% CI 1.27-4.74) and advanced imaging endoscopic techniques (OR 3.33, 95% CI 1.53-7.29).

CONCLUSIONS

Practice patterns for management of BE among endoscopists are variable. Attending training courses on BE improves adherence to guidelines.

Effect of bariatric surgery on in vitro fertilization in infertile men with obesity

BACKGROUND

Obesity has previously been related to reduced female fertility, with prolonged waiting time to pregnancy among women with a body mass index (BMI) >35 kg/m² but there are few studies investigating the relationship between high BMI, bariatric surgery, and male fertility.

OBJECTIVES

The primary objective of this article was to investigate the effect of bariatric surgery on in vitro fertilization (IVF) outcomes in a cohort of men with morbid obesity who underwent sleeve gastrectomy (SG).

SETTING

University hospital, bariatric surgery unit.

METHODS

Pre- and postsurgery data on patient age, body mass index (BMI), and variables related to male fertility (semen volume, concentration, progressively motile sperm count, and sperm morphology) were collected; assisted reproductive technology outcomes before and after bariatric surgery were measured by the number of metaphase II oocytes; the number of top-quality oocytes and embryos; the number of fertilized oocytes; the number of transferred embryo; the implantation rate; the pregnancy rate; the live birth rate and the miscarriage rate.

RESULTS

Thirty-five men with obesity and idiopathic infertility were included in this study. We found a significant increase, after bariatric surgery, in semen volume, total sperm concentration, progressively motile sperm count, and sperm morphology. Considering IVF outcomes, mean number of top-quality oocytes, mean number of fertilized oocytes, mean number of embryos obtained, and top-quality embryos were significantly increased after bariatric procedure.

CONCLUSION

Bariatric surgery is confirmed to be safe and effective in increasing the outcomes of assisted reproductive technology treatment also in case of infertile men with obesity, both in terms of pregnancy and live birth rate.

Endoscopic Submucosal Dissection for Visible Dysplasia Treatment in Ulcerative Colitis Patients: Cases Series and Systematic Review of Literature

BACKGROUND AND AIMS

Ulcerative colitis [UC] patients are at an increased risk of developing colorectal cancer due to chronic inflammation. Endoscopic submucosal dissection [ESD] allows removal of non-invasive neoplastic lesions in the colon, but few data are available on its efficacy in UC patients.

METHODS

Data from consecutive UC patients diagnosed with visible dysplastic lesions in the colon who underwent ESD were evaluated. The en bloc removal, R0 resection and complication rates were calculated. Local recurrence and metachronous lesions during follow-up were identified. A systematic review of the literature with pooled data analysis was performed.

RESULTS

A total of 53 UC patients [age: 65 years; range 30-74; M/F: 31/22] underwent ESD. The en bloc resection rate was 100%, and the R0 resection rate was 96.2%. Bleeding occurred in seven [13.2%] patients, and perforation in three [5.6%] cases, all treated at endoscopy. No recurrence was observed, but two metachronous lesions were detected. Data from six other studies [three Asian and three European] were available. By pooling data, en bloc resection was successful in 88.4% (95% confidence interval [CI] = 83.5-92) of 216 lesions and in 91.8% [95% CI = 87.3-94.8] of 208 patients. R0 resection was achieved in 169 ESDs, equivalent to a 78.2% [95% CI = 72.3-83.2] rate for lesions and 81.3% [95% CI = 75.4-86] rate for patients. No difference between European and Asian series was noted.

CONCLUSIONS

This pooled data analysis indicated that ESD is a suitable tool for safely and properly removing non-invasive neoplastic lesions on colonic mucosa of selected UC patients.

Safety in digestive endoscopy procedures in the covid era recommendations in progres of the italian society of digestive endoscopy

The new corona virus disease has started in Wuhan - China at the end of 2019 and quickly spread with a pandemic trend across the rest of the world. The scientific community is making an extraordinary effort to study and control the situation, but the results are just partial. Based on the most recent scientific literature and strong statements by the most prestigious international health institutions, the Italian Society of Digestive Endoscopy has drawn up some recommendations about the use of personal protective equipment, the correct way of dressing and undressing of endoscopists and nurses, before and after digestive endoscopy procedures. In addition, some other important indications are given to reduce the risk of contamination of healthcare providers during endoscopic activities, in the setting of a pandemic. Nevertheless, because of the very quick evolution of our knowledge on this issue, these recommendations must be considered as evolving, because they could change in a short time.

Endoscopic Submucosal Dissection of Gastric Neoplastic Lesions: An Italian, Multicenter Study

Endoscopic submucosal dissection (ESD) allows removing neoplastic lesions on gastric mucosa, including early gastric cancer (EGC) and dysplasia. Data on ESD from Western countries are still scanty. We report results of ESD procedures performed in Italy. Data of consecutive patients who underwent ESD for gastric neoplastic removal were analyzed. The en bloc resection rate and the R0 resection rates for all neoplastic lesions were calculated, as well as the curative rate (i.e., no need for surgical treatment) for EGC. The incidence of complications, the one-month mortality, and the recurrence rate at one-year follow-up were computed. A total of 296 patients with 299 gastric lesions (80 EGC) were treated. The en bloc resection was successful for 292 (97.6%) and the R0 was achieved in 266 (89%) out of all lesions. In the EGC group, the ESD was eventually curative in 72.5% (58/80) following procedure. A complication occurred in 30 (10.1%) patients. Endoscopic treatment was successful in all 3 perforations, whereas it failed in 2 out of 27 bleeding patients who were treated with radiological embolization (1 case) or surgery (1 case). No procedure-related deaths at one-month follow-up were observed. Lesion recurrence occurred in 16 (6.2%) patients (6 EGC and 10 dysplasia). In conclusion, the rate of both en bloc and R0 gastric lesions removal was very high in Italy. However, the curative rate for EGC needs to be improved. Complications were acceptably low and amenable at endoscopy.

First-line endoscopic treatment with over-the-scope clips in patients with either upper or lower gastrointestinal bleeding: a multicenter study

Background and study aims  Endoscopic treatment is the mainstay approach for gastrointestinal bleeding, in either upper (UGIB) or lower (LGIB) tract. The over-the-scope clip (OTSC) may overcome limitations of standard clips or thermocoagulation in high-risk bleeding lesions. We evaluate the main clinically relevant outcomes following endoscopic hemostasis with OTSC in high-risk lesions and/or patients. Patients and methods  This was a retrospective analysis of prospectively collected databases including all patients with UGIB and LGIB who underwent OTCS placement as first-line treatment in eleven tertiary endoscopic referral centers. Technical success, primary hemostasis, rebleeding, blood transfusion, hospital stay, and hemorrhage-related mortality rates were evaluated. Results  Data from 286 patients, with either UGIB (N = 214) or LGIB (N = 72) were available. Overall, 112 patients (39.2 %) were receiving antithrombotic therapy. Technical success and primary hemostasis rates were 97.9 % and 96.4 %, respectively. Early rebleeding occurred in 4.4 %, more frequently in those on antithrombotic therapy, and no late rebleeding was observed. Following a successful primary haemostasis, only 5.2 % patients needed blood transfusions, and the median hospital stay was 4 days (range: 3 - 11). Eighteen patients with either technical failure (N = 6) or rebleeding (N = 12) underwent radiological or surgical approaches. Overall, bleeding-related deaths occurred in 5 (1.7 %) patients, including 3 patients with technical procedural failure, and 2 in the rebleeding group.  Conclusions  Data from our large, multicenter study show that OTSC placement is an effective first-line treatment for hemostasis in high-risk patients and/or lesions both in upper and lower gastrointestinal tract.

Duodenal Epithelioid Angiosarcoma: Immunohistochemical and Clinical Findings. A Case Report

Angiosarcomas are uncommon malignant tumors of vascular endothelium that represent less than 1% of all sarcomas. The epithelioid variant of angiosarcomas is exceptionally rare, and the gastrointestinal tract is rarely involved. Angiosarcomas mainly involve skin and soft tissue and rarely occur in breast, liver, bone, and spleen. We present the case of a 30-year-old man who underwent an upper gastrointestinal endoscopy for melena. A duodenal reddish polypoid lesion was found, which on microscopic examination turned out to be an epithelioid angiosarcoma. The immunohistochemical features of the lesion supported this diagnosis. The patient died eight months after the diagnosis. Epithelioid angiosarcoma is an aggressive variant of angiosarcoma and must be considered in the differential diagnosis of gastrointestinal tumors.

Morbid Obesity: treatment with Bioenterics Intragastric Balloon (BIB), psychological and nursing care: our experience

Obesity is considered a chronic disease, difficult to treat, and is the first cause of death in the world that is predictable. The surgical approach is limited to patients with severe obesity but there is an intermediate group who are not candidates for immediate surgery. The BioEnterics Intragastric Balloon (BIB) is recommended for weight reduction as a bridge to bariatric surgery.

All patients in the study underwent a psychological evaluation prior to placement of the BIB.

Over-the-scope clips in the treatment of gastrointestinal tract iatrogenic perforation: A multicenter retrospective study and a classification of gastrointestinal tract perforations

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. Oval-shape 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.

Automodification of PARP and fatty acid-based membrane lipidome as a promising integrated biomarker panel in molecular medicine

AIM

Establishing by statistical analyses whether the analyses of auto-modified poly(ADP-ribose)polymerase and erythrocyte membrane fatty acid composition (Fat Profile(®)), separately or in tandem, help monitoring the physio-pathology of the cell, and correlate with diseases, if present.

PATIENTS & METHODS

Ninety five subjects were interviewed and analyzed blindly. Blood lymphocytes and erythrocytes were prepared to assay poly(ADP-ribose)polymerase automodification and fatty acid based membrane lipidome, respectively.

RESULTS

Poly(ADP-ribose)polymerase automodification levels confirmed their correlation with DNA damage extent, and allowed monitoring disease activity, upon surgical/therapeutic treatment. Membrane lipidome profiles showed lipid unbalance mainly linked to inflammatory states. Statistically both tests were separately significant, and correlated each other within some pathologies.

CONCLUSION

In the laboratory routine, both tests, separately or in tandem, might be a preliminary and helpful step to investigate the occurrence of a given disease. Their combination represents a promising integrated panel for sensible, noninvasive and routine health monitoring.

Endoscopic management of patients with post-surgical leaks involving the gastrointestinal tract: A large case series

BACKGROUND

Post-surgical anastomotic leaks often require a re-intervention, are associated with a definite morbidity and mortality, and with relevant costs. We described a large series of patients with different post-surgical leaks involving the gastrointestinal tract managed with endoscopy as initial approach.

METHODS

This was a retrospective analysis of prospectively collected cases with anastomotic leaks managed with different endoscopic approaches (with surgical or radiological drainage when needed) in two endoscopic centres during 5 years. Interventions included: (1) over-the-scope clip (OTSC) positioning; (2) placement of a covered self-expanding metal stent (SEMS); (3) fibrin glue injection (Tissucol); and (4) endo-sponge application, according to both the endoscopic feature and patient's status.

RESULTS

A total of 76 patients underwent endoscopic treatment for a leak either in the upper (47 cases) or lower (29 cases) gastrointestinal tract, and the approach was successful in 39 (83%) and 22 (75.9%) patients, respectively, accounting for an overall 80.3% success rate. Leak closure was achieved in 84.9% and 78.3% of patients managed by using a single or a combination of endoscopic devices. Overall, leak closure failed in 15 (19.7%) patients, and the surgical approach was successful in all 14 patients who underwent re-intervention, whilst one patient died due to sepsis at 7 days.

CONCLUSIONS

Our data suggest that an endoscopic approach, with surgical or radiological drainage when needed, is successful and safe in the majority of patients with anastomotic gastrointestinal leaks. Therefore, an endoscopic treatment could be attempted before resorting to more invasive, costly and risky re-intervention.

Retrieval of the gastric specimen following laparoscopic sleeve gastrectomy. Experience on 275 cases

Severe obesity leads to a high incidence of complications and a decrease in life expectancy, especially among younger adults. Laparoscopic sleeve gastrectomy (LSG) first intended as the first step of biliopancreatic diversion with duodenal switch is gaining a per-se procedure role because of its effectiveness on weight loss and comorbidity resolution. Different techniques have been described for specimen extraction in LSG. In this article we report the technique adopted in 275 LSGs performed in our department. In the first 120 LSGs performed from 2007, the specimen was extracted through a mini laparotomy. In the following 155 cases the technique has been simplified: the grasped specimen has been withdrawn through the 15 mm trocar site. We registered in the fist group six cases of wound infection (5%), ten cases of hematoma (8.3%) and four cases of port site hernia (3.3%). In the second group only one case of hematoma (0.6%, p = 0.01) but no cases of wound infection (p = 0.01) or port site hernia, (p = 0.03) although we registered a specimen perforation during retrieval in 16 patients, were reported. The technique described in the 155 cases of the control group has shown to be more effective than the technique we used in the case group, allowing significantly lower operative time (112.9 ± 1.0 vs 74.9 ± 9.1 p < 0.001) and complications, and providing unchanged costs.

Efficacy and safety of laparo-endoscopic resections of colorectal neoplasia: A systematic review

OBJECTIVE

The purpose of this review is to assess the efficacy and safety of laparo-endoscopic local resections for colorectal lesions not suitable for endoscopic resection.

SUMMARY BACKGROUND DATA

The combined laparo-endoscopic approach has been proposed for large colorectal lesions unsuitable for endoscopic resection, in order to reduce morbidity of common laparoscopic resection. However, data on the efficacy and safety of laparo-endoscopic local resections are still controversial.

METHODS

An Embase search of papers published during the period 1985-2014 was performed. Published studies that evaluated laparo-endoscopic resections for colorectal lesions were assessed using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) recommendations by two authors. Forest plots on primary (per-lesion rate of further surgery, including surgery for complications and surgery for oncologic radical treatment) and secondary outcomes were produced based on fixed and random effects models. Heterogeneity was assessed using the I (2) statistic. Risk for within-study bias was ascertained with QUADAS (Quality Assessment of Diagnostic Accuracy Studies) system.

RESULTS

A total of 11 studies provided data on 707 lesions treated with a combined laparo-endoscopic approach. A variety of techniques were reported. The overall per-lesion rate of further surgery was 9.5%, while per-lesion rate of further surgery for oncologic treatment was 7.9%, per-lesion rate of further surgery for complications treatment was 3.5%, incidence of adenocarcinoma was 10.5%, incidence of overall complications was 7.9%, incidence of conversion to open surgery 4.3% and incidence of recurrence was 5.4%.

CONCLUSIONS

Despite laparo-endoscopic approach ensures limited invasiveness, it is affected by a consistent rate of complications and oncologic inadequacy that often requires further surgical treatment.

Quality of bowel cleansing in hospitalized patients undergoing colonoscopy: A multicentre prospective regional study

BACKGROUND

Quality of bowel cleansing in hospitalized patients undergoing colonoscopy is often unsatisfactory. No study has investigated the inpatient or outpatient setting as cause of inadequate cleansing.

AIMS

To assess degree of bowel cleansing in inpatients and outpatients and to identify possible predictors of poor bowel preparation in the two populations.

METHODS

Prospective multicentre study on consecutive colonoscopies in 25 regional endoscopy units. Univariate and multivariate analysis with odds ratio estimation were performed.

RESULTS

Data from 3276 colonoscopies were analyzed (2178 outpatients, 1098 inpatients). Incomplete colonoscopy due to inadequate cleansing was recorded in 369 patients (11.2%). There was no significant difference in bowel cleansing rates between in- and outpatients in both colonic segments. In the overall population, independent predictors of inadequate cleansing both at the level of right and left colon were: male gender (odds ratio, 1.20 [1.02-1.43] and 1.27 [1.05-1.53]), diabetes mellitus (odds ratio, 2.35 [1.68-3.29] and 2.12 [1.47-3.05]), chronic constipation (odds ratio, 1.60 [1.30-1.97] and 1.55 [1.23-1.94]), incomplete purge intake (odds ratio, 2.36 [1.90-2.94] and 2.11 [1.68-2.65]) and a runway time >12h (odds ratio, 3.36 [2.40-4.72] and 2.53 [1.74-3.67]).

CONCLUSIONS

We found no difference in the rate of inadequate bowel preparation between hospitalized patients and outpatients.

Staple-line leak after sleve gastrectomy in obese patients: A hot topic in bariatric surgery

Laparoscopic sleeve gastrectomy is a surgical procedure that is being increasingly performed on obese patients. Among its complications, leaks are the most serious and life threatening. The placement of esophageal, covered, self-expandable metal stents in these cases has been performed by many authors but reports on the outcome of this procedure are limited and the technical aspects are not well defined. Stent migration is the main complication of the procedure and poses a challenge to the surgeon, with a limited number of options. Here we evaluate the technical and clinical outcome of a new, dedicated, self-expanding metal stent, comparing the advantages of this stent to those traditionally used to treat staple-line leak after sleeve gastrectomy. While published data are limited, they seem support the use of this kind of new stent as the best option for the stenting treatment of a staple-line leak after sleeve gastrectomy, over other kinds of stents. Further studies based on larger series are needed to better evaluate patient outcome.

Staple-line leak after sleve gastrectomy in obese patients: A hot topic in bariatric surgery

Laparoscopic sleeve gastrectomy is a surgical procedure that is being increasingly performed on obese patients. Among its complications, leaks are the most serious and life threatening. The placement of esophageal, covered, self-expandable metal stents in these cases has been performed by many authors but reports on the outcome of this procedure are limited and the technical aspects are not well defined. Stent migration is the main complication of the procedure and poses a challenge to the surgeon, with a limited number of options. Here we evaluate the technical and clinical outcome of a new, dedicated, self-expanding metal stent, comparing the advantages of this stent to those traditionally used to treat staple-line leak after sleeve gastrectomy. While published data are limited, they seem support the use of this kind of new stent as the best option for the stenting treatment of a staple-line leak after sleeve gastrectomy, over other kinds of stents. Further studies based on larger series are needed to better evaluate patient outcome.

A multimodal, one-session endoscopic approach for management of patients with advanced pancreatic cancer

BACKGROUND

A number of patients with inoperable pancreatic cancer may concurrently complain of pain, biliary obstruction, and duodenal stenosis. Endoscopic palliative treatments and opioid therapy are generally performed in these patients. The study aimed to assess the efficacy and safety of a multimodal 'one-Session Three Endoscopic Procedures' (one-STEP) to simultaneously treat cholestasis, restore duodenal transit, and achieve pain relief in selected patients with advanced pancreatic cancer.

METHODS

Selected patients diagnosed with an advanced pancreatic cancer presenting with biliary obstruction, duodenal stenosis, and severe pain treated with the one-STEP were considered. The one-STEP endoscopic approach included biliary and duodenal stenting, and EUS-guided celiac plexus neurolysis. The technical success rate, complications, pain relief, and opioid use at follow-up were assessed.

RESULTS

A total of 15 patients were treated. The one-STEP was successful in 13 (87 %) cases, while it failed in two patients due to the impossibility of dilating the neoplastic mass for creating a fistula. No endoscopy-related complications occurred. The median of pain intensity was 8 (range 7-10) at entry and significantly decreased to 2 (range 2-4) 72 h following celiac plexus neurolysis. At follow-up (median survival 4 months; range 3-8), only 3 (20 %) needed of narcotic treatment in the last period.

CONCLUSIONS

The multimodal one-STEP is an effective and safe endoscopic approach for palliative treatment of biliary and duodenal stenosis, and for relieving chronic pain in patients with advanced pancreatic cancer.

Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions

BACKGROUND AND AIMS

This systematic review and meta-analysis compares the safety and effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the treatment of flat and sessile colorectal lesions >20 mm preoperatively assessed as noninvasive.

METHODS

We reviewed the literature published between January 2000 and March 2014. Pooled estimates of the proportion of patients with en bloc, R0 resection, complications, recurrence, and need for further treatment were compared in a meta-analysis using fixed and random effects.

RESULTS

A total of 11 studies and 4678 patients were included. The en bloc resection rate was 89.9% for ESD vs 34.9% for EMR patients (RR 1.93 p < 0.001). The R0 resection rate was 79.6% for ESD vs 36.2% for EMR patients (RR 2.01 p < 0.001). The rate of perforation was 4.9% for the ESD group and 0.9% for EMR (RR 3.19, p < 0.001), while the rate of bleeding was 1.9% for ESD and 2.9% for EMR (RR 0.68, p = 0.070). Therefore, the overall need for further surgery, including surgery for oncologic reasons and surgery for complications, was 7.8% for ESD and 3.0% for EMR (RR 2.40, p < 0.001).

CONCLUSIONS

ESD achieves a higher rate of en bloc and R0 resection compared to EMR, at the cost of a higher risk of complications. This, added to an increased need for surgery for oncologic reasons for a plausible tendency to extend indication for endoscopic excision, increases the risk of further surgery after ESD.

A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution

BACKGROUND

Today a variety of bariatric surgical procedures is available and, currently, it is difficult to identify the most effective option based on patient characteristics and comorbidities. Aim of this retrospective study is to evaluate the efficacy of four different techniques; Intragastric Balloon (IB), Laparoscopic Adjustable Gastric Banding (LAGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Mini Gastric Bypass (LMGB), performed in our unit along ten years.

PATIENTS AND METHODS

Starting from January 2005, 520 patients, 206 men (39.6%) and 314 women (60.4%) were treated at our institution. Among patients candidate to bariatric surgery 145 underwent IB, 120 underwent LAGB, 175 underwent LSG and 80 underwent LMGB. Follow up rate was 93.1% for IB at 6 months; 74.1% and 48% for LAGB at 36 and 60 months respectively; 72.8% and 58.1% for LSG at 36 and 60 months respectively; and 84.2% for LMGB at 36 months.

RESULTS

The period 2005-2014 has been considered. Mortality was 1/520 patients (0.19%). The excess weight loss rate (EWL%) has been 32.8 for IB at six months, 53.7 for LAGB and 68.1 for LSG, at 60 months respectively and 79.5 for LMGB at 36 months. Early major postoperative complications requiring surgery were 0.6% for IB and 1.1% for LSG whereas late major postoperative complications were 1.2% for IB, 4.1% for LAGB and 0.5% for LSG. Diabetes resolution rate was 0 for LAGB, 76.9% for LSG and 80% for LMGB at 36 months.

CONCLUSIONS

If more invasive procedures as LSG or LMGB may entail higher operative and peroperative risks, conversely, in skilled hands their efficacy remains undisputed, especially in the long term, presenting a very low rate of major complications. In general, the efficacy of a bariatric surgery unit seems improved by the capability to offer both different primary procedures and re-do surgery.

A novel dedicated endoscopic stent for staple-line leaks after laparoscopic sleeve gastrectomy: a case series

BACKGROUND

Staple-line leak is the most serious complication of laparoscopic sleeve gastrectomy (LSG) occurring in .5-7% of cases. Patients with this complication are often managed with an esophageal covered, self-expandable metal stent positioned at endoscopy. Unfortunately, migration of these stents has been reported in 30-50% of cases. A novel fully-covered, self-expanding metal stent (Megastent), specifically designed for post-LSG leaks is now available. The objective of this study was to describe the first case series of patients with a staple-line leak after LSG who were endoscopically managed with such a novel stent.

METHODS

Four patients who developed a staple-line leak after LSG were treated by positioning a Megastent at endoscopy. The stents were removed after 8 weeks.

RESULTS

A complete leak repair was achieved in all patients. No stent migration occurred. Prokinetic therapy was needed to treat vomiting episodes during stent presence. At endoscopic evaluation after stent removal, a decubitus lesion at the distal part of the duodenal bulb was observed.

CONCLUSION

These preliminary results would suggest the use of the Megastent as an option for stenting of a staple-line leak after LSG. Further studies are still necessary.

Multiple lymphomatous polyposis with diffuse involvement of the gastrointestinal tract. Case report

The gastrointestinal tract is the predominant site of extranodal non-Hodgkin lymphomas. Multiple lynphomatous polyposis is a type of appearance of mantle cell lymphoma. It is characterized by multiple polypoid lesions involving long gastrointestinal tracts and it accounts for only approximately 1-2% of non-Hodgkin lymphomas. A 78 years old patient was admitted to our Department of General Surgery with rectal bleeding, abdominal pain and weight loss. Multiple lymphomatous polyposis was detected by endoscopy. Endoscopic biopsies confirmed the diagnosis of mantle cell lymphoma. The patient was transferred to the Department of Hematology for cycles of chemotherapy.

Endoscopic repair of post-surgical gastrointestinal complications

Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.

Biliary duct injuries in the laparoscopic era: our experience

AIM

The main aim of our study is to evaluate the incidence, the type, the causes and the therapy of biliary duct injuries which occurred after the video laparoscopic cholecystectomies performed in our Department during the period from 1990 to 2012.

PATIENTS AND METHODS

A retrospective analysis of 1186 VLC has been made in our Department from March 1990 to June 2012. Before the cholecystectomy all patient were evaluated with trans abdominal echography. Beyond the incidence of BDI was evaluated damaging mechanism, etiology, therapy and time of diagnosis.

RESULTS

From 1990 to 2012 a total of 9 BDIs occurred, with an incidence of 0,75%. Out of 9 patients 4 had major lesions and 5 had minor lesions; the most common BDI was Strasberg A (45%), the most common etiology was the presence of anatomical variations. In four cases the diagnosis has been intraoperative, in five cases has been postoperative.

CONCLUSIONS

Our clinical experience shows that the main cause of BDI are the surgeon experience and the bile ducts anatomical variation.

Difficult diagnosis of celiac disease: diagnostic accuracy and utility of chromo-zoom endoscopy

BACKGROUND

Chromo-zoom endoscopy has been demonstrated to be valuable in assessing the degree of intestinal villous atrophy in patients with suspected celiac disease.

OBJECTIVE

To evaluate the diagnostic accuracy of chromo-zoom endoscopy in patients with difficult diagnosis because of nonconcordant test results and/or the confounding of a gluten-free diet initiated before an appropriate diagnosis of celiac disease and to compare the findings to a recent reference standard, the in vitro gliadin challenge test.

DESIGN

Prospective, case-control study.

SETTING

Tertiary-care referral hospital.

PATIENTS

Patients without celiac disease (negative control group, n = 9), patients with celiac disease (positive control group, n = 41), and patients with difficult diagnosis (n = 27).

INTERVENTION

Chromo-endoscopy with indigo carmine and endoscopic zoom-magnification were performed. Duodenal fragments were collected for the in vitro gliadin challenge test. The area under the receiver operating characteristic curve (ROC) was used for statistical analyses on accuracy.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy of chromo-zoom endoscopy for detection of mucosal abnormalities in patients with difficult diagnosis.

RESULTS

Chromo-zoom endoscopy had a high accuracy for celiac disease diagnosis in analyses on negative controls and positive controls (area under roc = 0.99). In the difficult diagnosis group, the accuracy of chromo-zoom endoscopy was lower (area under roc = 0.83), but it increased after exclusion of patients with celiac disease on gluten-free diet (area under roc = 0.88).

LIMITATIONS

There was a 4% failure rate in the ability to cultivate biopsies. Also, the study was done at an academic medical center.

CONCLUSION

Chromo-zoom endoscopy has high accuracy for cases of difficult diagnosis of celiac disease but only in untreated patients with celiac disease.

Comparison between tungsten and steel polypectomy snares: evaluation of depth of colonic thermal wall injury in a pig model

BACKGROUND AND STUDY AIMS

Thermal injury of the colonic wall during polypectomy may induce complications such as bleeding and perforation. To date, the role of the snare material in these injuries has not been examined. The aim of this study was to evaluate the depth of colonic post-polypectomy thermal wall injury induced by tungsten and steel endoscopic snares, in an effort to reduce electrosurgery-related complications.

MATERIALS AND METHODS

This was a single tertiary center experimental study in a porcine model. A total of 90 polypectomies where performed in three live pigs under general anesthesia, using both steel and tungsten snares by cut, coagulation, and blend current modes. The pigs were then euthanized and their colons examined histologically.

RESULTS

Steel snares induced significantly deeper tissue injury than tungsten snares in the pure cut mode (Pearson χ2 = 6.136, P = 0.013). The ordinal logistic regression analysis showed that the current mode and snare material were significantly associated with the ordinal score for the depth of injury. Thus, cut mode was positively associated with a lower score and coagulation mode with a higher score. In addition, tungsten was significantly associated with a lower depth of tissue injury.

CONCLUSIONS

Due to its inherent electrical properties, tungsten is very well suited for manufacture into electrosurgical endoscopic devices. Thus, tungsten snares may be advantageous for routine use in endoscopic polypectomy, although further studies are needed to confirm these promising findings in human patients.

High technology imaging in digestive endoscopy

A thorough endoscopic visualization of the digestive mucosa is essential for reaching an accurate diagnosis and to treat the different lesions. Standard white light endoscopes permit a good mucosa examination but, nowadays, the introduction of powerful endoscopic instrumentations increased ability to analyze the finest details. By applying dyes and zoom-magnification endoscopy further architectural detail of the mucosa can be elucidated. New computed virtual chromoendoscopy have further enhanced optical capabilities for the evaluation of submucosal vascolar pattern. Recently, confocal endomicroscopy and endocytoscopy were proposed for the study of ultrastructural mucosa details. Because of the technological contents of powerful instrumentation, a good knowledge of implemented technologies is mandatory for the endoscopist, nowadays. Nevertheless, there is a big confusion about this topic. We will try to explain these technologies and to clarify this terminology.

Retroperitoneal schwannoma unusually presenting as severe constipation

Retroperitoneal schwannomas are rare tumours originating from Schwann cells of peripheral nerve sheaths. Their clinical presentation is often delayed as they grow to a large size in a non-restrictive space, such as the retroperitoneum, before any clear symptomatology is manifested. Furthermore, the symptoms may mimic different diseases and be aspecific. The preoperative diagnosis is often unclear as no pathognomonic radiological features are known. Fine needle biopsy is not diagnostic due to tumour cell pleomorphism. We report the case of a 51-year-old woman presenting with unusual symptoms such as severe constipation, bowel distension, excess flatus, postprandial fullness and abdominal pain due to left colon compression by a large retroperitoneal tumour. A complete resection of the mass combined with sparing of the surrounding tissues was carried out through a midline laparotomy. Microscopic evaluation and immunohistochemistry documented a benign retroperitoneal schwannoma. Postoperatively, complete resolution of abdominal symptoms and no major complications were observed. At 28 months' follow-up no local recurrence was found. To the best of our knowledge, this is a rare case of retroperitoneal schwannoma with definite abdominal symptoms and with sudden onset of severe constipation.

Diagnosis and therapeutic management of cystic dystrophy of the duodenal wall in heterotopic pancreas. A case report and revision of the literature

CONTEXT

Cystic dystrophy in heterotopic pancreas is a rare and serious condition. Diagnosis is difficult because of non-specific clinical manifestations and radiologic and endoscopic imaging are pivotal. Therapeutic management is still under debate.

CASE REPORT

We describe a case of cystic dystrophy of the duodenal wall in heterotopic pancreas complicated with chronic pancreatitis and pancreatic cystadenoma.

DISCUSSION

Computed tomography and magnetic resonance are very useful in demonstrating the presence of cysts in a thickened duodenal wall but, for the most part, endoscopic ultrasonography is the most useful imaging examination. The choice of different therapeutic options is still under debate; although some authors have proposed a medical approach using octreotide or endoscopic treatment for selected patients, a pancreaticoduodenectomy is usually proposed for symptomatic patients.

CONCLUSION

When surgery is needed, a pancreaticoduodenectomy is preferred, reserving by-pass procedures for high risk patients. Because of the non-specific clinical manifestation and the very difficult diagnosis and therapeutic management, these patients should be studied and treated in specialized and dedicated centers.

Pancreaticoduodenectomy as the primary therapeutic choice in cystic dystrophy of the duodenal wall in heterotopic pancreas

On the basis of a review of the literature and description of a clinical case, the aim of this paper was to evaluate the role of pancreaticoduodenectomy as the primary therapeutic choice in a rare, serious condition such as cystic dystrophy of the duodenal wall in heterotopic pancreas. The diagnosis is difficult because of the non-specific clinical manifestations, and radiological and endoscopic imaging are decisive. Computed tomography and magnetic resonance are very useful for demonstrating the presence of cysts in a thickened duodenal wall but endoscopic ultrasonography is the most useful imaging examination. The choice of therapeutic option is still debated. Although some Authors have proposed a medical approach using octreotide or endoscopic treatment for selected patients, pancreaticoduodenectomy is usually proposed for symptomatic patients. When surgery is needed, pancreaticoduodenectomy should be preferred, reserving by-pass procedures for high-risk patients. Because of the non-specific clinical manifestations and the very difficult diagnostic and therapeutic management, these patients need to be studied and treated in specialised, dedicated centres.

Hydatid disease of the liver: thirty years of surgical experience

Hydatid disease of the liver is a relatively frequent disease. Although the natural history is almost completely known, several complications may occur. The aim of this study was to show that radical surgical resection of the hepatic hydatid cyst is a safe and very effective technique, based on our results after 30-year experience. A review of most significant studies was carried out. We retrospectively evaluated our surgical cases. From January 1973 to December 2003 we treated 216 patients, 98 males and 118 females. Survival was compared with the Kaplan-Meier test, using log-rank analysis to compare data. Differences with a p value less than 0.05 were considered significant. A total of 279 cysts were excised. We performed pericystectomy in 122 cases, 73 of which closed. We also performed 19 atypical resections, 10 segmentectomies, 20 lobectomies and 2 percutaneous treatments. In more than 90% of cases, preoperative data collection was completed by preoperative ultrasound. The cumulative morbidity was 13%. The recurrence rate amounted to 4.3% at 5 years and 7% at 10 years: of these, 6 occurred after non-radical surgery and 2 after total pericystectomy or liver resection (p < 0.001). Technical advances and accumulated experience permit safe treatment of hepatic hydatid cysts by radical resection, with an almost zero recurrence rate, making it the treatment of choice over partial resection. The utility of percutaneous treatment remains confined to limited indications, such as laparoscopy.

New technique for endoscopic removal of intragastric balloon placed for treatment of morbid obesity

BACKGROUND

Placement and removal of the intragastric balloon for obesity are performed endoscopically often under general anesthesia. We propose a safer and faster technique for endoscopic removal of the intragastric balloon using standard sedation.

METHODS

In 87 obese patients, we performed 3 removal techniques: 1) standard gastroscope and foreign body forceps, 2) standard gastroscope and retrieval snare, 3) double-channel gastroscope and foreign body forceps plus symmetrical "shark model" polypectomy snare. Balloon retrieval time, number of times the grasping devices lost the balloon, amount of antispasmodic drug, symptoms cumulative score and VAS score for discomfort were evaluated.

RESULTS

The technique by double-channel gastroscope and foreign body forceps plus symmetrical polypectomy shark retrieval snare showed a significantly lower balloon retrieval time, number of lost balloons, total number of ampoules used, symptoms cumulative score and VAS score compared to the other two techniques (Dunn's P<0.05). Number of lost balloons was positively associated with number of antispasmodic ampoules used, balloon retrieval time and VAS score.

CONCLUSIONS

Technique by double-channel gastroscope and foreign body forceps plus symmetrical polypectomy shark retrieval snare, allows balloon removal safely, quickly and easily, avoiding loss of the balloon, with good patient endurance.

Technical aspects in endoscopic biopsy of lesions in esophageal pemphigus vulgaris

BACKGROUND AND AIMS

Aim of this study is to compare a specific kind of biopsy forceps to a traditional one in providing an adequate specimen of esophageal pemphigus vulgaris lesions that includes the basement membrane for definitive diagnosis.

PATIENTS AND METHODS

Prospective, randomized, blind, single-center study. We performed upper endoscopy with biopsy in 32 patients divided into two groups of 16 each: in group A with a commercially available standard biopsy forceps while in group B with a commercially available rocking biopsy forceps. Hundred-ninety-six biopsy specimens from both groups were blindly evaluated by the same pathologist.

RESULTS

In group A 18.8% of biopsy specimens were adequate (basement membrane included). In group B 87.5% of biopsy specimens were adequate. The presence of the entire thickness of the mucosa was significantly higher in group B compared to group A. All parameters typically taken into account by pathologist for diagnosis of esophageal pemphigus vulgaris were significantly improved in group B.

CONCLUSIONS

The biopsy forceps used in group B permits a rocking motion of the tip on contact with the mucosa, produces a deeper full-thickness mucosal sample up to the basement membrane and assists in the evaluation of histologic features of esophageal pemphigus vulgaris.

Proximal stomach function in obesity with normal or abnormal oesophageal acid exposure

There is an increased prevalence of gastro-oesophageal reflux and symptoms in obese patients. Information about the proximal stomach in obese patients with reflux is lacking. Gastric volume and compliance are similar between obese and lean subjects. To study the proximal stomach function and perception in obese patients with normal or abnormal oesophageal acid exposure, thirty-one obese patients, with normal or abnormal oesophageal acid exposure, underwent medical evaluation of oesophageal and gastrointestinal symptoms by a questionnaire and measurement of proximal stomach function and perception by an electronic barostat and a standardized questionnaire. Nineteen obese patients had abnormal oesophageal acid exposure. The percentage of total time with pH <4 is significantly related to the presence of hiatal hernia, the oesophageal intensity-frequency symptom score and gender, i.e. higher percentage in men. The perception cumulative score was significantly different between patients with normal and abnormal oesophageal acid exposure after adjusting for covariates (gender, body mass index, age, minimal distending pressure, gastric tone and gastric compliance). Gastric tone and compliance were significantly related to the perception cumulative score. In conclusion, patients with abnormal oesophageal acid exposure have increased gastric perception. A significant relation among gastric tone, gastric compliance and upper gastrointestinal sensations was shown.

Laparoscopic antireflux surgery: indications, preoperative evaluation, techniques, and outcomes

BACKGROUND/AIMS

During the past decade, the development of mini-invasive surgery has determined a resurgence in popularity of the antireflux surgery. The purpose of this study is to examine indications, preoperative evaluation, surgical techniques, and outcomes after mini-invasive surgery.

METHODOLOGY

From 1996 to 2000, 25 patients with gastroesophageal reflux disease associated to hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24h-pH monitoring, endoscopic evidence of esophagitis, and defective lower esophageal sphincter. Nissen fundoplication was performed in 16 patients with normal esophageal body motility, and 270 degrees posterior fundoplication in 9 patients with low esophageal motility.

RESULTS

Mortality and conversion rate were 0. Mean operative time was 130 minutes and mean postoperative hospital stay 5 days. Twenty-four (96%) patients were completely cured of reflux symptoms off all medications. Transient, mild postoperative dysphagia occurred in 3 patients (12%). There was a significant improvement of the results in postoperative esophageal manometry and 24h-pH monitoring.

CONCLUSIONS

Despite the fact that few patients were treated by using laparoscopic approach, results are encouraging with less morbidity and great advantages for patients. Precise selection of patients and surgical techniques are essential.

The role of upper endoscopy in identifying oesophageal involvement in patients with oral pemphigus vulgaris

BACKGROUND AND AIMS

The involvement of oesophagus in pemphigus vulgaris is still debated. The aims of this study were to evaluate the prevalence of oesophageal involvement and the gastro-duodenal mucosa appearance before and after high-dose corticosteroid therapy in a group of patients with oral pemphigus vulgaris.

METHODS

We prospectively studied 28 consecutive patients with oral pemphigus by oesophageal symptom standardised questionnaire, upper gastro-intestinal endoscopy, exfoliative cytology and histological biopsy. After clinical remission, all patients underwent new endoscopy.

RESULTS

The prevalence of oesophageal symptoms was 57.1%. Endoscopic examination revealed oesophageal involvement with different degrees of severity in 67.8% of patients. After corticosteroid therapy, endoscopy showed normal oesophageal-gastro-duodenal mucosa. No examination-related exacerbations of the oesophageal lesions were seen.

CONCLUSIONS

The upper gastro-intestinal endoscopic examination, in oral pemphigus vulgaris patients with oesophageal symptoms, is safe in skilled hands technique and a useful diagnostic tool prior to starting therapy.

Added value of CT colonography after a positive conventional colonoscopy: impact on treatment strategy

BACKGROUND

Conventional colonoscopy (CC) requires an experienced operator to avoid technical or interpretative errors, and an endoscopic error rate of 14% for tumor localization has been reported. We evaluated the impact of computed tomographic colonography (CTC) on surgical treatment strategy in patients with CC reported as having colorectal neoplasm.

METHODS

Fifty-three patients testing positive for colorectal neoplasm on CC underwent CTC: 32 patients had CC in our hospital (group A) and 21 had CC in area hospitals (group B). All CTC procedures were performed with a multidetector CT system. The results of CTC and CC were compared with that of surgery. The preoperative surgical planning evaluated on the basis of CC and CTC was compared with the actual surgical approach, and the percentage of patients in whom CTC modified the treatment strategy suggested by CC was calculated.

RESULTS

CTC changed the treatment strategy in four of 53 patients (7.5%) in whom CC showed technical or interpretative errors. Group analysis showed that CTC did not influence the surgical management in any patient in group A but did affect treatment strategy in four of 21 patients (19%) in group B. The effect of CTC on treatment strategy between groups was statistically significant (p < 0.05). CTC identified five adenomas and three adenocarcinomas localized proximally to an impassable stenosis.

CONCLUSION

CTC can be used to reevaluate the findings of a positive CC and can indicate a more correct therapeutic approach in patients with colorectal neoplasms who are candidates for surgery.

Long-term follow-up after endoscopic biliary stent placement for bile duct strictures from laparoscopic cholecystectomy

BACKGROUND/AIMS

The outcome of endoscopic biliary stent insertion for postoperative bile duct stenosis was retrospectively evaluated.

METHODOLOGY

Fifty-seven patients with biliary stenosis from laparoscopic cholecystectomy were included from February 1992 to January 2000. One to three stents were inserted for an average of 12.4 months, with stent exchange every 3 months to avoid cholangitis caused by clogging.

RESULTS

Successful stent insertion was achieved in 43/57 (75.4%) patients. Stent insertion failed in 10 patients with complete and in 4 patients with incomplete biliary obstruction. Early complications occurred in 4 patients. Late complications occurred in 5/43 patients. Five patients experienced recurrence of stenosis.

CONCLUSIONS

Endoscopic treatment should be the initial management of choice for postoperative bile duct stenosis.