Endoscopic submucosal dissection for superficial premalignant and malignant epithelial neoplasms of the digestive tract: a real-life experience in Italy

OBJECTIVE

Endoscopic submucosal dissection (ESD) is a technique for en bloc resection of neoplastic lesions of the digestive tract. Endoscopic submucosal dissection was developed in Asia, and data from Western countries are scarce. Our study aimed to assess the efficacy and safety of ESD for resection of superficial premalignant and malignant epithelial neoplasms in a tertiary center in Italy.

PATIENTS AND METHODS

All patients with gastrointestinal lesions who underwent ESD between January 2013 and December 2018 in our center were retrospectively evaluated. Technical success, en bloc, R0, curative resection, and complication rates were assessed.

RESULTS

A total of 107 lesions (stomach, no.=41; rectum, no.=32; colon, no.=28; esophagus, no.=5; duodenum, no.=1) were resected by ESD in 93 patients. Endoscopic submucosal dissection was technically successful in 99.1% (106/107) of lesions. Among the 90 superficial premalignant and malignant epithelial neoplasms, en bloc, and R0 resection rates were 97.8% (no.=88) and 75.6% (no.=68), respectively. Major complications occurred in 9.3% (10/107) of cases: 4 (3.7%) were perforations and 6 (5.6%) were major bleedings. All complications, but two which needed surgery, were managed endoscopically.

CONCLUSIONS

Our study shows that ESD is a feasible, effective, and safe technique in a Western country.

Ankle impingement: a review of multimodality imaging approach

Ankle impingement is defined as entrapment of an anatomic structure that leads to pain and decreased range of motion of the ankle and can be classified as either soft tissue or osseous (Bassett et al. in J Bone Joint Surg Am 72:55-59, 1990). The impingement syndromes of the ankle are a group of painful disorders that limit full range of movement. Symptoms are due to compression of soft-tissues or osseous structures during particular movements (Ogilvie-Harris et al. in Arthroscopy 13:564-574, 1997). Osseous impingement can result from spur formation along the anterior margin of the distal tibia and talus or as a result of a prominent posterolateral talar process, the os trigonum. Soft-tissue impingement usually results from scarring and fibrosis associated with synovial, capsular, or ligamentous injury. Soft-tissue impingement most often occurs in the anterolateral gutter, the medial ankle, or in the region of the syndesmosis (Van den Bekerom and Raven in Knee Surg Sports Traumatol Arthrosc 15:465-471, 2007). The main impingement syndromes are anterolateral, anterior, anteromedial, posterior, and posteromedial impingement. These conditions arise from initial ankle injuries, which, in the subacute or chronic situation, lead to development of abnormal osseous and soft-tissue thickening within the ankle joint. The relative contributions of the osseous and soft-tissue abnormalities are variable, but whatever component is dominant there is physical impingement and painful limitation of ankle movement. Conventional radiography is usually the first imaging technique performer and allows assessment of any potential bone abnormality, particularly in anterior and posterior impingement. Computed tomography (CT) and isotope bone scanning have been largely superseded by magnetic resonance (MR) imaging. MR imaging can demonstrate osseous and soft-tissue edema in anterior or posterior impingement. MR imaging is the most useful imaging modality in evaluating suspected soft-tissue impingement or in excluding other ankle pathology such as an osteochondral lesion of the talus. MR imaging can reveal evidence of previous ligamentous injury and also can demonstrate thickened synovium, fibrosis, or adjacent reactive soft-tissue edema. Studies of conventional MR imaging have produced conflicting sensitivities and specificities in assessment of anterolateral impingement. CT and MR arthrographic techniques allow the most accurate assessment of the capsular recesses, albeit with important limitations in diagnosis of clinical impingement syndromes. In the majority of cases, ankle impingement is treated with conservative measures, with surgical debridement via arthroscopy or an open procedure reserved for patients who have refractory symptoms. In this article, we describe the clinical and potential imaging features, for the four main impingement syndromes of the ankle: anterolateral, anterior, anteromedial, posterior, and posteromedial impingement.

Magnetic resonance imaging in brachial plexus injury

Brachial plexus injury represents the most severe nerve injury of the extremities. While obstetric brachial plexus injury has showed a reduction in the number of cases due to the improvements in obstetric care, brachial plexus injury in the adult is an increasingly common clinical problem. The therapeutic measures depend on the pathologic condition and the location of the injury: Preganglionic avulsions are usually not amenable to surgical repair; function of some denervated muscles can be restored with nerve transfers from intercostals or accessory nerves and contralateral C7 transfer. Postganglionic avulsions are repaired with excision of the damaged segment and nerve autograft between nerve ends or followed up conservatively. Magnetic resonance imaging is the modality of choice for depicting the anatomy and pathology of the brachial plexus: It demonstrates the location of the nerve damage (crucial for optimal treatment planning), depicts the nerve continuity (with or without neuroma formation), or may show a completely disrupted/avulsed nerve, thereby aiding in nerve-injury grading for preoperative planning. Computed tomography myelography has the advantage of a higher spatial resolution in demonstration of nerve roots compared with MR myelography; however, it is invasive and shows some difficulties in the depiction of some pseudomeningoceles with little or no communication with the dural sac.

7T mMR in the assessment of acute arterial mesenteric ischemia in a rat model

To validate a rat model of acute arterial mesenteric ischemia correlating MRI patterns with macro and microscopic changes in the small bowel. Thirty Sprague-Dawley rats were assigned to two experimental groups (Group I and Group II) of fifteen rats each. Group I underwent surgical procedure of superior mesenteric artery (SMA) ligation, followed by macroscopic observation. In Group II, a loop was tied loosely around the SMA without occluding the vessel. Three days after surgery, the loop was tied by external tips to completely occlude the artery. 7T microMR (7Tesla microMR) was performed before and 8 hours after SMA occlusion. At predetermined time-points the histopathological examinations were performed in both of groups. Macroscopic monitoring revealed thinning of mesenteric vessels, hypotonic reflex ileus and chromatic change of some loops. 7T microMR sequences evidenced loop dilation with gas-fluid mixed stasis, intraperitoneal free fluid and bowel wall hyperintensity. There were no significant differences in the histological analysis between the two groups. The gap of three days from surgery, adopted in the Group 2, allowed to avoid signs of peritoneal and mesenteric irritation which could bias imaging patterns. MR succeeded to identify the signs of arterial mesenteric ischemia.

Ventricular nuclei-DNA relationships with myocardial growth and hypertrophy in the rat

Rat ventricles, ranging from 306 to 1999 mg, were obtained from normal animals of different ages and from animals subjected to chronic aortic constriction. The concentration of DNA in the paired ventricles (right and left) was found to be closely related to the concentration of nuclei in the left ventricular papillary muscles. Muscle nuclei represented only 10 to 15% of this population of nuclei. In young animals (phase 1), the total ventricular content of muscle nuclei, nonmuscle nuclei, and of DNA were increasing with ventricular growth. In the adult rat (phase 2), the total ventricular content of DNA and of both muscle and nonmuscle nuclei remained relatively constant with ventricular growth. In the enlarged hearts (phase 3), there was a further increase in total ventricular DNA but there was no further increase in the total number of muscle nuclei. Spectrophotometric studies (Feulgen stain), showed that 88% of the muscle nuclei belonged to a single ploidy class (probably diploid). No relation could be demonstrated between the extent of nuclear polyploidy and the weight of the ventricles. It was concluded that polyploidy was not a significant factor in the increased total DNA of phase 3. The increased ventricular DNA of phase 3 was explained by the proliferation of the nonmuscle nuclei.