Optimizing the Personalized Care for the Management of Rectal Cancer: A Consensus Statement

Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acıbadem Mehmet Ali Aydınlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.

Upper socioeconomic status is associated with lower Helicobacter pylori infection rate among patients undergoing gastroscopy

INTRODUCTION

Socioeconomic factors play an important role in the prevalence of Helicobacter pylori (HP) infection. The aim of this study is to investigate HP prevalence among symptomatic patients in the upper socioeconomic segment of the population undergoing gastroscopy in an endemic urban region.

METHODOLOGY

Over a 12-month period, data were collected from the first consecutive 1000 patients (500 from university hospital, 500 from community hospital) who had gastroscopy and HP evaluation.

RESULTS

Overall, 211/1000 patients (21.1 %) were found to have HP in gastric biopsies. The specificity, sensitivity, positive predictive value, negative predictive value and diagnostic accuracy of rapid urease test were 87.5%, 99.7%, 99%, 96.5%, and 96.9% respectively. Atrophic gastritis, gastric and duodenal ulcers were significantly more common in HP positive patients. Age based distribution of HP prevalence: > 6 decades (15.5%), 3rd-5th decades (26.1%), < 3rd decades (10.4%).

CONCLUSION

In an HP endemic country, the prevalence of HP infection among symptomatic patients belonging to the upper socioeconomic segment of the population appears to be markedly lower. The lowest prevalence in young patients is expected to result in future decrease in HP prevalence.

Lesion size determines diagnostic yield of EUS-FNA with onsite cytopathologic evaluation for upper gastrointestinal subepithelial lesions

BACKGROUND/AIMS

The aim of this study was to determine the diagnostic yield and factors influencing the diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for upper gastrointestinal (GI) subepithelial lesions (SELs) with rapid onsite cytopathologic evaluation.

MATERIALS AND METHODS

This is a single-center, retrospective study.

RESULTS

Among 22 patients who underwent EUS-FNA, a cytopathological diagnosis was reached in 16 (72.7%) patients. The EUS-FNA results were as follows: seven GISTs (31.8%), six leiomyomas (27.2%), four non-diagnostics (18%), two duplication cysts (9%), two spindle cell tumor (9%), and one ectopic pancreas (4.5%). The long-axis size was > 20 mm in 12 patients (average size: 31.3 ±9.3 mm) and < 20 mm (average size: 16.6 ±2.5 mm) in 10 patients. Diagnostic accuracy of EUS-FNA from lesions < 20 mm was 50% (5/10 lesions), and of lesions > 20 mm was 91.6% (11/12 lesions) (Fisher's exact test; p=0.028). Six patients underwent surgical resection. Surgical pathology results of five lesions (four GIST, one leiomyoma) were consistent with cytopathology results (83.3%).

CONCLUSION

The diagnostic yield of EUS-FNA of the upper GI SELs with an onsite cytopathologic interpretation was 72.7%. Lesion size < 2 cm significantly reduces the diagnostic yield of EUS-FNA for the upper GI SELs.

Endoscopic papillectomy of benign ampullary lesions: Outcomes from a multicenter study

BACKGROUND/AIMS

Endoscopic papillectomy (EP) has emerged as an alternative to surgery in the management of ampullary lesions. The aim of this study is to evaluate feasibility, efficacy, safety, outcome, and impact of EP in the management of benign ampullary lesions.

MATERIALS AND METHODS

This is a multicenter, retrospective study of 44 patients who had EP of benign ampullary lesions.

RESULTS

Over the 11-year period, 44 (55.7%) of 79 patients underwent EP for benign ampullary lesions. Complete resection was achieved in 40 patients (91%). An underlying adenocarcinoma was the only risk factor for incomplete resection. Twenty-eight lesions (63.6%) were resected en-bloc and 16 lesions (36.4%) were resected in piecemeal fashion. Post-papillectomy histopathologic diagnoses were tubular adenoma in 14 patients (32%), invasive adenocarcinoma in 9 patients (20.5%), tubullovillous adenoma in 7 patients (16%), tubullovillous adenoma with carcinoma limited to the mucosal layer in 5 patients (11.3%), adenoma with high-grade dysplasia in 4 patients (9%), neuroendocrine tumor in 1 patient (2.3%), ganglioneuroma in 1 patient (2.3%), hamartomatous polyp in 1 patient (2.3%), adenofibroma in 1 patients (2.3%), and Brunner gland hyperplasia in 1 patient (2.3%). Seven (15.9%) procedure-related complications occurred: 3 (6.8%) bleeding, 2 (4.5%) pancreatitis, 1 (2.3%) abdominal pain, and 1 (2.3%) stent migration to the pancreatic duct. Seven patients (17%) had recurrence.

CONCLUSION

Endoscopic papillectomy is a safe and effective method and can be considered as a first-line approach in patients with benign ampullary lesions with intent for cure. It also allows for correct histological diagnosis and staging.

Vildagliptin-induced acute pancreatitis without enzyme elevation

We describe 2 patients with diabetes mellitus, presenting with upper abdominal pain. Although imaging findings were consistent with acute pancreatitis (AP), serum amylase and lipase levels were within normal limits. In both the cases, the only identifiable diagnostic culprit was vildagliptin. This is the first reported case of vildagliptin causing AP clinically and radiographically without elevated serum pancreatic enzymes. In conclusion, even when serum amylase and lipase levels are normal, AP should be kept in mind when making a differential diagnosis of patients with diabetes mellitus who present with abdominal pain and take dipeptidyl peptidase-4 (DPP-4) inhibitors.

Eosinophilic jejunitis presenting as intractable abdominal pain

Eosinophilic gastroenteritis is an uncommon disease characterized by eosinophilic infiltration of the gastrointestinal tract. The clinical manifestations are related to the layer(s) and extent of the bowel involved. In this paper, we present a case of intractable abdominal pain caused by jejunal submucosal eosinophilic infiltration without mucosal involvement, diagnosed by deep endoscopic biopsies. The patient was successfully treated with steroids without need for surgery for diagnosis or therapy.

Endoscopic ultrasound in patients over 80 years old

BACKGROUND

The data on the safety and utility of EUS in patients over 80 years of age is limited.

OBJECTIVE

We investigated the indications, feasibility, safety, and clinical utility of EUS in the management of GI, pancreatobiliary, and mediastinal diseases.

DESIGN

Retrospective study.

SETTING

A tertiary referral university hospital.

PATIENTS

Consecutive patients ≥80 years of age referred over a 9-year period for EUS evaluation.

RESULTS

A total of 265 EUS scans were performed in 232 patients with a mean age of 83.8 years. The indications for pancreatobiliary EUS were to evaluate a pancreatic mass (n = 60), pancreatic cyst (n = 18), pancreatitis (n = 10), dilated CBD in the setting of jaundice and/or biliary stricture (n = 20), dilated CBD with no jaundice and/or biliary stricture (n = 20). The indications for luminal gastrointestinal EUS were esophageal lesions (n = 21), gastric lesions (n = 30), duodenal lesions (n = 14), rectal lesions (n = 22), and gastrointestinal subepithelial lesions (n = 28). The indications for mediastinal EUS were mass/lymphadenopathy (n = 14). EUS-guided FNA (EUS-FNA) was performed in 95 (35.8%) cases and results were consistent or suspicious for a malignancy in 62 cases (65.2%). Endoscopic mucosal resection (EMR) was performed in 17 cases (6.41%) on the same session following endosonographic evaluation. The procedure was successful in all patients with no complications related to sedation, EUS, or EUS-FNA encountered. One patient had perforation following EMR.

LIMITATION

Retrospective study.

CONCLUSIONS

EUS and EUS-FNA are feasible and safe and have a significant impact on the management of GI, pancreatobiliary and mediastinal diseases in extreme elderly.

Endoscopic submucosal dissection for premalignant lesions and noninvasive early gastrointestinal cancers

AIM: To investigate the indication, feasibility, safety, and clinical utility of endoscopic submucosal dissection (ESD) in the management of various gastrointestinal pathologies.

METHODS: The medical records of 60 consecutive patients (34 female, 26 male) who underwent ESD at the gastroenterology department of Kocaeli University from 2006-2010 were examined. Patients selected for ESD had premalignant lesions or non-invasive early cancers of the gastrointestinal tract and had endoscopic and histological diagnoses. Early cancers were considered to be confined to the submucosa, with no lymph node involvement by means of computed tomography and endosonography.

RESULTS: Sixty ESD procedures were performed. The indications were epithelial lesions (n = 39) (33/39 adenoma with high grade dysplasia, 6/39 adenoma with low grade dysplasia), neuroendocrine tumor (n = 7), cancer (n = 7) (5/7 early colorectal cancer, 2/7 early gastric cancer), granular cell tumor (n = 3), gastrointestinal stromal tumor (n = 2), and leiomyoma (n = 2). En bloc and piecemeal resection rates were 91.6% (55/60) and 8.3% (5/60), respectively. Complete and incomplete resection rates were 96.6% (58/60) and 3.3% (2/60), respectively. Complications were major bleeding [n = 3 (5%)] and perforations [n = 5 (8.3%)] (4 colon, 1 stomach). Two patients with colonic perforations and two patients with submucosal lymphatic and microvasculature invasion (1 gastric carcinoid tumor, 1 colonic adenocarcinoma) were referred to surgery. During a mean follow-up of 12 mo, 1 patient with adenoma with high grade dysplasia underwent a second ESD procedure to resect a local recurrence.

CONCLUSION: ESD is a feasible and safe method for treatment of premalignant lesions and early malignant gastrointestinal epithelial and subepithelial lesions. Successful en bloc and complete resection of lesions yield high cure rates with low recurrence.

EUS in pediatric patients

BACKGROUND

The knowledge of EUS use in children is limited.

OBJECTIVE

We investigated the indications, feasibility, safety, and clinical utility of EUS in the management of pediatric GI, pancreatobiliary, and mediastinal diseases.

DESIGN

Retrospective study.

SETTING

Two tertiary referral university hospitals.

PATIENTS

Consecutive children age younger than 18 years referred over a 7-year period for EUS evaluation.

RESULTS

Forty EUS scans were performed in 38 children with a mean age of 13.5 years. The indications for pancreatobiliary endosonography were pancreatitis (n = 10), solid pancreatic mass (n = 7), cystic pancreatic mass (n = 1), cyst in the setting of chronic pancreatitis (n = 1), suspected annular pancreas (n = 1), celiac plexus block (n = 1), suspected common bile duct stone (n = 1), abdominal pain and atrophic pancreas (n = 1), ampullary adenoma (n = 1), and abnormal MRCP in a patient with jaundice (n = 1). The indications for gastric EUS were mucosal lesions (n = 2) and subepithelial lesions (n = 4). The indications for mediastinal endosonography were mediastinal masses/lymph nodes (n = 5). The remaining evaluations were performed for esophageal stricture (n = 1), unexplained abdominal pain (n = 1), unexplained abdominal pain with celiac axis block (n = 1), and perirectal fluid collection (n = 1). EUS-guided FNA (EUS-FNA) was performed in 12 (30%) cases and established the correct diagnosis in 9 (75%). EUS-guided fine-needle injections for celiac axis block were performed in 2 (5%) cases. The procedure was successful in all patients, and no complications related to sedation, EUS, or EUS-FNA were encountered.

LIMITATION

Retrospective study.

CONCLUSION

EUS and EUS-FNA are feasible and safe and have a significant impact on the management of pediatric GI, pancreatobiliary, and mediastinal diseases.

Duodenal variceal bleeding successfully treated with transjugular intrahepatic portosystemic shunt: a case report and review of the literature

Duodenal varices are uncommon causes of gastrointestinal bleeding. In the literature, treatment of duodenal variceal bleeding is limited to case reports and case series. Treatment options are endoscopic, interventional radiologic and surgical modalities. In this article, we presented a case of a successful duodenal variceal bleeding treatment with transjugular intrahepatic portosystemic shunt. The other treatment modalities are also reviewed.

Role of endoscopic ultrasound in superficial esophageal cancer

The recent increase in the incidence of superficial esophageal cancer and promising developments in potentially curative endoscopic therapies have placed endoscopic ultrasound in a central position with regard to decision making. This is a review of the literature to determine the role of endoscopic ultrasound and high frequency probe ultrasonography in the assessment of superficial esophageal carcinomas.

Severe pulmonary toxicity after azathioprine/6-mercaptopurine initiation for the treatment of inflammatory bowel disease

Azathioprine and 6-mercaptopurine (6-MP) are effective in inflammatory bowel disease (IBD). However, between 10% and 29% of patients treated with these drugs are forced to stop therapy due to side effects. Pulmonary toxicity due to azathioprine/6-MP has been reported infrequently. We describe 3 patients who developed severe, noninfectious pulmonary toxicity within 1 month after the initiation of azathioprine or 6-MP for the treatment of IBD colitis (2 Crohn's disease and 1 ulcerative colitis). All patients presented with dyspnea, cough, and fever after initiation of azathioprine/6-MP. Evaluation for infectious etiologies, including bronchoscopy (3/3 patients) and open-lung biopsy (2/3 patients) was negative. Histopathologic examination of the lung biopsies revealed bronchiolitis obliterans organizing pneumonia in one, and usual interstitial pneumonitis in another patient. Cessation of purine analog therapy resulted in clinical improvement in all 3 cases. Azathioprine/6-MP-related pulmonary toxicity is a rare but serious side effect, and it is important for clinicians to have a high index of suspicion for this adverse reaction which occurs within 1 month after initiation of treatment for IBD.

Intrahepatic portal hypertension secondary to metastatic carcinoma of the prostate

While the liver is a common site of metastasis, tumor metastases are not a common cause of portal hypertension. We report a case of a patient with symptomatic portal hypertension due to diffuse metastatic prostate carcinoma infiltration of liver parenchyma that was not appreciated with routine imaging.

Gastric calcifying fibrous tumor

Intramucosal gastric tumours are most commonly found to be gastrointestinal stromal tumours or leiomyomas (smooth muscle tumours); however, a variety of other uncommon mesenchymal tumours can occur in the stomach wall. A rare benign calcifying fibrous tumour is reported and the endoscopic appearance, ultrasound findings and morphology are documented. A review of the literature found only two similar cases.

Esophageal intramural pseudodiverticulosis with food impaction

Esophageal intramural pseudodiverticulosis is a rare condition of unknown etiology originally described in 1960. It is characterized by multiple, flask-shaped outpouchings of pinhead size in the wall of the esophagus. Very small outpouchings on endoscopy and tiny collections of barium outside of the esophagus wall on esophagography are typical diagnostic findings. During the era of widespread endoscopic and radiological evaluation of esophageal disorders, approximately 200 cases were published in the literature. A 52-year-old man with esophageal intramural pseudodiverticulosis with food impaction is reported. The patient's symptoms of dysphagia resolved with endoscopic dilations and proton pump inhibitor therapy.

Feasibility and safety of endoscopic evaluation of gastric emptying

BACKGROUND AND STUDY AIMS

Scintigraphy is the currently accepted method for evaluation of gastric emptying. Although quantitative, this method is complicated, time-consuming, and costly. If a simple endoscopic technique was available for those instances when quantification of an emptying abnormality is not needed, the same clinical information could be obtained in less time and with resource savings. Our aims in this study were therefore to assess the technical feasibility, tolerability, and safety of unsedated transnasal esophagogastroscopy (T-EG) as a technique for qualitative assessment of gastric emptying.

METHODS

The study was done in two phases. In the first phase, 18 volunteers (ten men, eight women) underwent T-EG at 4 hours, 5 hours, or 6 hours after ingestion of a standard meal used for scintigraphic evaluation of gastric emptying without radiolabeling. In the second phase, ten volunteers underwent T-EG after scintigraphic imaging had demonstrated complete gastric emptying.

RESULTS

Subjects in both phases tolerated the procedure well and completed the study. In the first phase, 13 of 15 volunteers exhibited complete gastric emptying at 6 hours (87%), while two (13%) revealed some particulate matter in the stomach at that time. In the second phase, one of the ten volunteers exhibited a small amount of solid food residue in the stomach despite documentation of scintigraphic complete emptying.

CONCLUSIONS

Evaluation of gastric emptying by unsedated T-EG is both feasible and safe. In healthy, asymptomatic individuals, complete gastric emptying of solid food may take as long as 6 hours.

Mesenteric venous thrombosis in inflammatory bowel disease

Mesenteric venous thrombosis (MVT) is a rare but potentially catastrophic clinical complication, which may lead to ischemia or infarction of the intestine and/or the emergence of portal hypertension. An association between inflammatory bowel disease (IBD) and MVT has previously been described, but clinical factors that may contribute to this complication in the setting of IBD are not well characterized. Diagnosis of MVT in IBD is difficult, as patients frequently present with nonspecific abdominal discomfort, which may delay diagnosis and initiation of treatment. We report 6 of 545 IBD patients at our center (1.1%) that developed MVT, and describe presentation, diagnostic approaches, treatment options, underlying contributing factors, and outcome. The diagnosis was determined with abdominal computed tomography (CT) in 5 of 6 cases. Clinical factors, which were thought to contribute to MVT, included underlying hypercoagulability, low-flow state, uncontrolled inflammation, perioperative time period, and prior surgical manipulation of the portal vein following orthotopic liver transplantation. There were no deaths as a result of MVT, although 1 patient developed severe portal hypertension and another experienced intestinal infarction requiring extensive resection. We conclude that MVT is an important clinical consideration in IBD patients, specifically during the perioperative setting, and diagnosis is facilitated with the use of CT scan.

[Surgical colpo-suspension (Burch's method) in the management of female stress incontinence]

Colposuspension operation was carried out with Burch's technique for the treatment of stress incontinence of women. The results and experiences of the authors are described. Detailed urodynamic examination was carried out before the operation. Fifty-five operations of this type were performed during three and a half years: complete continence was reached in 51 cases and 4 cases showed improvement. The authors are of the opinion that this surgical technique offers better results than the vaginally performed interventions.