Endoscopic minor papilla sphincterotomy in patients with complete pancreas divisum and acute recurrent pancreatitis: a metanalysis

BACKGROUND AND AIMS

Pancreas divisum (PD) is a congenital variant of the pancreatic ductal system and a potential cause of acute recurrent pancreatitis (ARP). Endoscopic minor papilla sphincterotomy (MiES) is the most common procedure performed in the management of PD-related ARP. The aim of this study is to perform a meta-analysis estimating the efficacy and the safety of MiES in the management of patients with PD-related ARP.

METHODS

A research was performed in Pubmed, EMBASE and Web of science, the studies were reviewed and selected according to inclusion and exclusion criteria. Evaluation of Heterogeneity and publication bias was performed, and a random effect model was used to estimate the effect size of each study.

RESULTS

One hundred and thirteen articles were selected and reviewed, 13 met the inclusion criteria. All the studies were retrospective with a mean follow-up duration of 45.9 months. A total of 323 patients with PD-related ARP treated with MiES were included in the meta-analysis. The overall clinical success rate of MiES (defined as no further episodes of ARP, reduction of episodes of ARP, or improvement in quality of life) was of 77% (95%CI: 72%-81%; p = 0.30). Evaluating only the studies with clinical success rate defined as "no further AP in the follow-up" the clinical success rate was of 69.8% (95%CI: 61.3%-77.2%; p = 0.57), while evaluating the studies with other definitions (reduction of episodes of ARP or improvement in quality of life) the clinical success rate was of 81.2% (95%CI: 75.2%-86.1%; p = 0.45). The common fixed effects model disclosed a 25.5% overall adverse events rate (95%CI: 19.3%-32.8%; p = 0.42): acute pancreatitis in 14.3% (95%CI: 9.7%-20.6%; p = 0.36), bleeding in 5.6% (95%CI: 2.9%-10.4%; p = 0.98), and other adverse events in 5.6% (95%CI: 2.9%-10.4%; p = 0.67).

CONCLUSION

MiES is an effective and relatively safe treatment in the management of PD-related ARP. The retrospective nature of the studies selected is the main limitations of this metanalysis. Prospective trials are needed to confirm these data.

Endoscopic pancreatic sphincterotomy in patients with IPMN-related recurrent pancreatitis: A single center experience

BACKGROUND

Acute recurrent pancreatitis (ARP) is a rare manifestation of Intraductal Papillary Mucinous Neoplasms (IPMN) of the pancreas; ARP is a relative indication for pancreatic surgery in the setting of IPMN. Endoscopic pancreatic sphincterotomy (EPS) has been described as a minimal invasive treatment to reduce the episodes of ARP secondary to mucus migration in IPMN.

METHODS

patients with IPMN-related ARP treated with ESP from January 2004 to December 2020 were retrospectively selected. Clinical and technical data were recorded. A clinical follow-up (minimum 12 months) was performed to assess the number of episodes of AP occurring after EPS.

RESULTS

25 patients were included. The mean follow-up after ESP was 93.4 months (SD± 56.6). The mean number of AP before and after EPS were respectively 3.29 (SD ± 1.04) and 0.51 (SD ± 0.71). A complete response (no further episodes of AP) and a partial response (>50% reduction of AP episodes) were obtained in 64% and 24% of the cases, respectively, with an overall response rate of 88%. One post-EPS bleeding and one minor-papilla stenosis were reported and were endoscopically managed. Two patients underwent pancreatic resection for the occurrence of high-risk stigmata for cancer progression.

CONCLUSIONS

EPS is a safe and effective treatment to reduce the number of episodes of AP in selected patients with IPMNs-related ARP. Prospective trials are needed to confirm these data.

P17.18.B Augmentative craniotomy in recurrent glioblastoma. Preliminary clinical and radiological outcomes

Background

The compression of peritumoral healthy tissue in brain tumor patients is considered a major cause of life-threatening neurologic symptoms. This condition is associated with an increase in intracranial pressure. The literature reports that GBM has a mass effect in 72% of autoptic brains of patients who died of brain tumor, with herniation in 50% of all cases.

Material and methods

We present a preliminary clinical series on 5 cases. The patients are chosen based on criteria of recurrent glioblastoma without the possibility of a gross total resection with a recurrence after STUPP protocol. The surgeries include cytoreduction and augmentative craniotomy. The aim is to increase the intracranial volume and reduce the intracranial pressure in evolving glioblastoma. Clinical and radiological follow-up considers different objective scales and contrast enhancement MRI performed every 3 months. We evaluate KPS, survival rate, complication rate, quality of life using QOL-BN20 and neuropsychological assessment.

Results

The 12 months of follow-up shows a mean survival rate of 9 months after the surgery. This procedure has no negative impact on the survival rate, complication rate, and quality of life reduction. The neuropsychological evaluation does not show an impact on self-perception of aesthetic appearance. The surgery does not show surgical wound complications. The mean operative time was 225 minutes and was comparable with standard recurrence glioblastoma procedure.

Conclusion

This work has the main limitation of being preliminary results on small population. However, these results show encouraging outcomes and could be an innovative and salvage therapy for recurrent and incurable glioblastoma. Further follow-up and study must be performed.

Porcine coronary arteries: immunohistochemical profile of TNF-alpha, IL-1beta, TGF-beta1 and ICAM-1

BACKGROUND

In our study we used immunohistochemical technique to demonstrate the presence of the cytokines tumour necrosis factor alpha (TNF-α), interleukin 1beta (IL-1β), transforming growth factor beta1 (TGF-β1) and intercellular adhesion molecule-1 (ICAM-1) in porcine coronaries even in physiological conditions.

MATERIALS AND METHODS

Inflammatory cytokines are polypeptide mediators which act as a communication signal between immune system cells and other types of cellsin different organs and tissues, both in human and pig coronary circulation.

RESULTS

Our results show that pro-inflammatory cytokines TNF-α, IL-1β, TGF-β1 and ICAM-1 are also present in the medium tunica of the coronary arteries under physiological conditions. These results may be compared with those found in coronary atherosclerosis, where the increase in TNF-α has a dramatic effect on the function of the left ventricle, and the high value of IL-1 correlates directly with the extent of myocardial necrosis. In our study we observe the damage and activation of endothelial cells; this induces endothelial dysfunction by accumulation and oxidation of low density lipoproteins (LDL). The formation of oxidized LDL could play a central role in the amplification of the inflammatory response causing an increased expression of pro-inflammatory cytokines which promotes leukocyte recruitment in the intimal layer. These leukocytes, after the adhesion to the endothelium, penetrate the intimate tunic.

CONCLUSIONS

Therefore inflammatory processes promote the onset and evolution of atheroma and the development of thrombotic complications.

Endoscopic snare papillectomy: a possible radical treatment for a subgroup of T1 ampullary adenocarcinomas

Pancreaticoduodenectomy is the standard care for invasive ampullary adenocarcinomas. However, endoscopic snare papillectomy (ESP) might play a curative role in very selected patients. We studied a series of 15 patients with T1 ampullary adenocarcinoma who were treated by ESP alone and followed up for a mean of 29.6 ± 21.9 months (range 8 - 81 months). ESP was curative for eight patients (57.1 %). No tumor-related death was observed in patients with a cancer infiltration depth of ≤ 4 mm. According to this preliminary experience, we suggest that this measurable variable threshold should be considered as a possible basis for future large-scale studies.

Role of endoscopic sphincterotomy of the minor papilla in pancreas divisum

BACKGROUND

Pancreas divisum (PD) is a common anatomical variant of the pancreatic duct system. Only a little percentage of patients with this altered anatomy develop symptoms: acute recurrent pancreatitis (ARP), chronic pancreatitis (CP) and pancreatic-type pain alone. These have been supposed to arise from an obstruction to outflow of the pancreatic dorsal duct due to a stenosis of the minor papilla. Endoscopic sphincterotomy of the minor papilla (MiES) can be considered an effective treatment for patients with PD and ARP supported by stenosis or obstruction of the minor papilla. On the other hand, the access through the minor papilla is essential for therapeutic pancreatic endoscopy in patients with PD and CP, but the effectiveness of MiES in these patients is extremely controversial.

MATERIALS AND METHODS

Aim of this brief review has been to evaluate the short and long-term effects of endoscopic pancreatic interventions in patients affected by symptomatic PD who underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy of the minor papilla (MiES). The main literature database was Medline (1966-2013).

RESULTS

Data come from a personal overview of articles emerging from the same search strategy.

CONCLUSIONS

Nowadays, when endoscopic pancreatic drainage is indicated in patient with symptomatic PD, access through the minor papilla (MiP) is required. Therapeutic endoscopic interventions provide less invasive alternatives to the surgical approach.

Endoscopic hemostasis with fibrin glue for refractory postsphincterotomy and postpapillectomy bleeding

BACKGROUND

Bleeding is a feared complication of endoscopic sphincterotomy and papillectomy. Fibrin glue has been proposed as an effective adjunct in securing hemostasis. However, its use has been limited by the risk of early occlusion of the injecting needle, and its role has not been defined in the setting of refractory post-ERCP bleeding. We present a modified technique of endoscopic hemostasis with diluted fibrin glue in the setting of postsphincterotomy and postpapillectomy bleeds.

OBJECTIVE

We aimed to verify that diluted fibrin glue can be easily and successfully injected and is effective in the endoscopic treatment of refractory post-ERCP bleeding.

DESIGN

Case series.

SETTING

A tertiary-care academic medical center.

PATIENTS

Six patients with refractory post-ERCP bleeding were treated (3 after sphincterotomy and 3 after papillectomy) with fibrin glue injection.

INTERVENTION

Endoscopic hemostasis with diluted fibrin glue injection.

MAIN OUTCOME MEASUREMENTS

Successful endoscopic hemostasis with diluted fibrin glue injection.

RESULTS

One session of fibrin glue injection stopped the refractory post-ERCP bleeding in all 6 patients.

LIMITATION

Small number of patients.

CONCLUSION

This case series provides evidence that our modified injection technique of diluted fibrin glue allowed an easy submucosal injection and may be considered to be an effective endoscopic modality to treat refractory post-ERCP bleeding.

Study of the effects of transoral gastroplasty on insulin sensitivity and secretion in obese subjects

BACKGROUND AND AIMS

Transoral gastroplasty (TOGA) recently emerged as a new, feasible and relatively safe technique for the surgical treatment of obesity. However, so far there are no data on the effects on insulin sensitivity in the literature. Our aim is to evaluate the effect of TOGA on insulin sensitivity and secretion.

METHODS AND RESULTS

Nine glucose normo-tolerant obese subjects (age:41+/-6 years; BMI:42.49+/-1.03 kg/m(2)) were studied. Fat-free mass (FM) and fat mass (FM) were assessed by bioelectrical impedance; plasma glucose, insulin, and C-peptide were measured during an oral glucose tolerance test (OGTT) before and 3 months after the operation. Insulin sensitivity was calculated using the oral-glucose insulin-sensitivity index, and insulin secretion by C-peptide deconvolution. Three months after surgery, a significant (P=0.008) reduction of BMI to 35.65+/-0.65 kg/m(2), with a decrease of FM and FFM from 57.22+/-2.19 to 41.46+/-3.02 kg (P=0.008) and from 59.52+/-1.36 to 56.67+/-1.10 kg (P=0.048) respectively, was observed. Insulinemia was significantly reduced at fast and at 120 min after OGTT; in contrast, no significant change in glucose concentration was observed. Insulin sensitivity significantly increased (348.45+/-20.08 vs. 421.18+/-20.84 ml/min/m(2), P=0.038) and the incremental area of insulin secretion rate (total ISR) significantly decreased (from 235.05+/-27.50 to 124.77+/-14.50 nmol/min/m(2), P=0.021). Total ISR correlated with weight, BMI and FM (r=0.522, P=0.028; r=0.541, P=0.020; r=0.463, P=0.049, respectively). BMI represented the most powerful predictor of ISR decrease (R(2)=0.541, P=0.020).

CONCLUSION

Transoral gastroplasty allows a significant weight loss 3 months after the intervention as well as an amelioration of insulin sensitivity with subsequent reduction of the insulin secretion.

Endoscopic gallbladder drainage for acute cholecystitis: technical and clinical results

BACKGROUND AND STUDY AIMS

Cholecystectomy is the standard treatment for acute cholecystitis while percutaneous drainage is reserved for high-risk patients. The aim of the present study was to assess the technical success rate and clinical efficacy of endoscopic gallbladder drainage in patients with acute cholecystitis.

PATIENTS AND METHODS

A total of 35 consecutive patients with acute cholecystitis and without residual common bile duct obstruction were retrospectively identified. Patients were stratified according to the pathogenesis and stages of acute cholecystitis, and the morphology of the cystic duct and/or its insertion in the common bile duct. Primary outcomes were technical success and early and late clinical success.

RESULTS

Endoscopic retrograde cholangiopancreatography (ERCP) was performed within the first 72 hours in 19 patients (54%). Technical success was achieved in 29 patients (83%); drainage was nasocholecystic in 21 of these (72%), plastic stenting in 6 (21%), and a combined method in 2 (7%). The pathogenesis and stage of acute cholecystitis, and the morphology both of the cystic duct and its insertion in the common bile duct, did not influence technical success. Clinical success was achieved in 24 cases (83%) after a median of 3 days (range 2-12). Four patients (14%) died within 3 days due to septic complications, and one accidentally removed the nasocholecystic drain after 24 hours. Late results, available in 21 patients after a median follow-up of 17 months, showed relapse of acute cholecystitis in 2 (10%) (both with stents) and of biliary pain in 2 patients (10%), both of whom had nasocholecystic drainage.

CONCLUSIONS

Endoscopic gallbladder drainage seems feasible and effective in resolving acute cholecystitis, but only as a temporary measure because of a 20% relapse rate in long-term follow-up. Prospective studies are necessary to identify which patients would benefit most from this endoscopic technique in the short and long term.

Combined endoscopic stent insertion in malignant biliary and duodenal obstruction

BACKGROUND AND STUDY AIMS

Self-expandable metal stents (SEMS) are an effective palliative treatment for malignant biliary and duodenal strictures. Combined biliary and duodenal stenting remains a technical challenge, however. The aim of this study was to evaluate the technical feasibility of an endoscopic approach to double stenting of malignant biliary and duodenal strictures.

PATIENTS AND METHODS

Consecutive patients referred for palliative gastroduodenal and biliary stenting were followed up prospectively. Patients' demographic characteristics, the site and nature of the strictures, success rates, complications, and survival time were recorded.

RESULTS

A total of 64 patients underwent double stenting. In 46 patients, biliary obstruction occurred before the onset of duodenal obstruction (by a median of 107 days) (group 1); in 14 patients, biliary obstruction occurred concurrently with duodenal obstruction (group 2); and in four patients the duodenal obstruction preceded the biliary obstruction (by a median of 121 days) (group 3). The duodenal strictures were proximal to the papilla in 31 patients, adjacent to the papilla in 25 patients and distal to the papilla in eight patients. The majority of biliary strictures were in the middle or distal third of the bile duct (in 52/64 patients). Duodenal SEMS were successfully deployed in all patients. Combined endoscopic stenting was successful in 100% of patients in group 1, 86% of patients in group 2, and in 100% of patients in group 3. Taking the three groups together, early complications occurred in 6% of patients and late complications occurred in 16% of patients. The overall median survival after combined stenting was 81 days (range 2-447 days).

CONCLUSIONS

Combined endoscopic biliary and duodenal SEMS insertion is safe and effective for palliation in malignant biliary and duodenal obstruction. Biliary stenting through the mesh of the duodenal SEMS is technically feasible and has a high success rate.

Flexible endoscopic Zenker's diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique

BACKGROUND AND STUDY AIM

The standard treatment for a Zenker's diverticulum is diverticulotomy, either using the endostapling approach or by surgery. Flexible endoscopic diverticulotomy has similar efficacy and is associated with fewer complications but this technique is still under investigation. The aim of this study was to compare the technical results and efficacy of two flexible endoscopic diverticulotomy techniques.

PATIENTS AND METHODS

A total of 39 patients with a Zenker's diverticulum were treated using either cap or diverticuloscope assistance to expose the septum, which was then cut with a needle-knife and endocut currents. The severity of symptoms was graded according to their frequencies before the procedure, after 1 month, and to June 2006.

RESULTS

Of the 39 patients enrolled into the study, 28 patients were treated with the cap and 11 with the diverticuloscope, the two groups showing no statistical difference in baseline features. The median length of the Zenker's diverticulum was 4 cm (range 2-8 cm). The procedure time was significantly longer with the cap than with diverticuloscope assistance (P = 0.002). Complications occurred in 9/28 patients in the cap group and in none of the patients in the diverticuloscope group (P = 0.04); the perforations that occurred in five patients (18%) were managed endoscopically and conservatively. The median inpatient stay was 3 days (range 2-8 days). The clinical remission rate, evaluated using a pool of symptoms, was significantly higher after the diverticuloscope-assisted procedure compared with the cap technique (82% vs. 29%, P = 0.004). Multivariate analysis showed that the diverticuloscope-assisted technique was the only significant prognostic factor for efficacy (odds ratio 13.09, 95% CI 2.07-82.53).

CONCLUSION

The use of the soft diverticuloscope to expose and fix the septum seems to be the optimal approach in terms of increasing the safety and clinical efficacy of flexible endoscopic diverticulotomy.

Nonendoscopic transnasal placement of a wireless capsule for esophageal pH monitoring: feasibility, safety, and efficacy of a manometry-guided procedure

BACKGROUND AND STUDY AIMS

The aim of the study was to evaluate the safety, feasibility, and efficacy of transnasal placement of the Medtronic Bravo capsule for wireless esophageal pH monitoring.

PATIENTS AND METHODS

Forty patients with symptomatic gastroesophageal reflux disease were prospectively evaluated. All patients underwent upper gastrointestinal endoscopy and esophageal manometry. The Bravo capsule was then introduced transnasally and released 5 cm above the upper margin of the lower esophageal sphincter. Serial radiographs were performed weekly until capsule release.

RESULTS

Of the 40 patients who were evaluated, 38 (95 %) were eligible to undergo the procedure. Transnasal placement proved impossible in one patient (2.5 %). Overall, a total of 39 procedures were performed in 38 patients (the procedure was repeated in one patient because of accidental intragastric fixation). Esophageal placement was successful in 36/39 procedures (92.3 %). The mean duration of the procedure was 10 minutes (range 5 - 16 minutes). Adverse events were noted in five of the 39 procedures (12.8 %), mild epistaxis in two patients (5.1 %) and pharyngeal irritation in three patients (7.7 %). After the procedure, a slight "foreign body" sensation was reported by 20 of the 36 patients (55.5 %) who had undergone successful esophageal placement; two patients (5.5 %) experienced severe retrosternal pain necessitating endoscopic removal of the capsule. At the end of the study, 34 of the 38 patients (89.5 %) stated that they would be willing to undergo the test again if necessary.

CONCLUSIONS

Transnasal placement of the Bravo pH capsule is safe, well tolerated, does not require sedation, and avoids endoscopy and its complications.

Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results

BACKGROUND AND STUDY AIMS

Dominant pancreatic duct strictures located in the head of the pancreas in patients with severe chronic pancreatitis are often managed by endoscopic placement of a single plastic stent. Patients with refractory strictures after prolonged stenting require repeated stent replacement or surgical pancreaticojejunostomy. Placement of multiple plastic stents has proved effective in managing postoperative biliary strictures. The aim of this study was to investigate the feasibility, efficacy, and long-term results of multiple stenting of refractory pancreatic strictures in severe chronic pancreatitis.

PATIENTS AND METHODS

19 patients with severe chronic pancreatitis (16 men, three women; mean age 45 years) and with a single pancreatic stent through a refractory dominant stricture in the pancreatic head underwent the following protocol: (i) removal of the single pancreatic stent; (ii) balloon dilation of the stricture; (iii) insertion of the maximum number of stents allowed by the stricture tightness and the pancreatic duct diameter; and (iv) removal of stents after 6 to 12 months.

RESULTS

The median number of stents placed through the major or minor papilla was 3, with diameters ranging from 8.5 to 11.5 Fr and length from 4 to 7 cm. Only one patient (5.5 %) had persistent stricture after multiple stenting. During a mean follow-up of 38 months after removal, 84 % of patients were asymptomatic, and 10.5 % had symptomatic stricture recurrence. No major complications were recorded.

CONCLUSION

Endoscopic multiple stenting of dominant pancreatic duct strictures in chronic pancreatitis is a feasible and safe technique. Multiple pancreatic stenting is promising in obtaining persistent stricture dilation on long-term follow-up in the setting of severe chronic pancreatitis.

A novel diagnostic tool for detecting functional patency of the small bowel: the Given patency capsule

BACKGROUND AND STUDY AIMS

The current visualization of small-bowel strictures using traditional radiological methods is associated with high radiation doses and false-negative results. These methods do not always reveal small-bowel patency for solids. The aim is to assess the safety of the Given patency system and its ability to detect intestinal strictures in patients with strictures that are known or suspected radiologically.

MATERIALS AND METHODS

The Given patency capsule is composed of lactose, remains intact in the gastrointestinal tract for 40-100 hours post ingestion, and disintegrates thereafter. A total of 34 patients with small-bowel stricture were prospectively enrolled; 30 had a previous diagnosis of Crohn's disease, three had adhesion syndrome and in one ischemic enteritis was suspected. Of the patients, 15 (44.1 %) had previously undergone surgery. Following ingestion, the capsule was monitored for integrity and transit time, using a specially designed Given scanner and also radiologically. Seventeen patients had been enrolled with the intent of using the patency capsule as a preliminary test in patients with small-bowel strictures before undergoing video capsule endoscopy.

RESULTS

30 patients (88.2 %) retrieved the capsule in the stool; it was intact in 20 (median transit time 22 hours), and disintegrated in 10 patients (median transit time 53 hours). Six patients complained of abdominal pain which disappeared within 24 hours. The scanner successfully indicated the presence of the capsule in 94 % of cases. Ten patients underwent video capsule endoscopy following the patency capsule examination; in all of these the video capsule passed through the small-bowel stricture.

CONCLUSIONS

This feasibility study has shown that the Given patency capsule is a safe, effective, and convenient tool for assessment of functional patency of the small bowel. It can indicate functional patency even in cases where traditional radiology indicates stricture.

External pancreatic fistulas resistant to conventional endoscopic therapy: endoscopic closure with N-butyl-2-cyanoacrylate (Glubran 2)

External pancreatic fistulas may follow abdominal surgery or injury. While most respond to conservative management or endoscopic intervention, others might require surgery for complete healing. We report four cases of patients with external pancreatic fistulas that failed to respond to conservative management and drainage. N-butyl-2-cyanoacrylate surgical glue (Glubran 2) was directly injected into the fistulous tract. The fistulas closed within 24 hours of the Glubran 2 injection in three cases (75 %). In patients with external pancreatic fistulas that fail to respond to conservative and endoscopic drainage, injection of Glubran 2 directly into the fistulous tract may lead to closure, thus avoiding the need for surgical intervention.

Endoscopic clipping of a colocutaneous fistula following necrotizing pancreatitis: case report

The case described here is of a 73-year-old male patient who developed a colocutaneous fistula following necrotizing pancreatitis, diagnosed by imaging and treated endoscopically by the application of an endoclip. Pancreatic and gastrointestinal fistulas, common complications of surgery for necrotizing pancreatitis, frequently require surgical treatment. Colonic perforations are the most difficult to treat surgically on account of the risk of peritonitis. A technique, namely, endoscopic clips application, has recently been developed to close anastomotic leakages and perforations of the oesophagus, stomach and colon. In the patient described here, endoscopic repair was technically easy and the good result was confirmed within a few days. In order to repair colonic fistulas following pancreatitis, application of endoclips could, in our opinion, provide a useful therapeutic option, feasible in selected patients.

An endoscopic approach to the management of surgical bile duct injuries: nine years' experience

BACKGROUND

The evaluation of the endoscopic treatment of surgical bile duct injuries, especially in the management of post-operative strictures, remains controversial.

AIM

The aim of this study was to evaluate the feasibility of using endoscopic management from a study of the clinical reports of two of the main endoscopy units in Sicily.

PATIENTS AND METHODS

A total of 137 consecutive patients were selected. There were 85 simple biliary fistulas: 64 from the cystic duct stump; 19 from the gall bladder bed; and two from intra-hepatic bile ducts. There were 52 biliary lesions: 15 complete transections; 12 incomplete lesions of the common bile duct with six associated strictures; five complete or incomplete sections of the right antero-medial duct; and 20 incomplete strictures (without leak).

RESULTS

The success rate was 96.3% for simple biliary fistulas. Endoscopic therapy was feasible only in 40.6% of lesions of the common bile duct or the right antero-medial duct (13/32), but with 100% success. In the case of strictures (with or without associated leak), there was a good outcome in 88.2% of patients who completed the therapeutic procedure.

CONCLUSIONS

Endoscopic management of simple biliary fistulas and incomplete lesions of the common bile duct is the preferred approach. If continued for 12-24 months, with the placement of three or more 10F stents, the management of stenoses is guaranteed to yield good results.

Endoscopic treatment of Barrett's epithelium with Argon Plasma Coagulation. Long-term follow-up

BACKGROUND

Barrett's esophagus (BE) is a premalignant condition for the development of esophageal adenocarcinoma. Recently, many endoscopic therapies based on thermal or photobiologic ablation of BE have been provided, with positive short-term results in 60-100% of cases, but long-term results are still lacking. The aim of this study is to evaluate long-term results of BE endoscopic ablation with Argon-Plasma Coagulation (APC).

METHODS

Thirty-five consecutive patients were treated (every 3 weeks) with APC until the eradication of BE and the squamous epithelium restoration were assessed. During the treatment and the first 6 months of follow-up, patients received 40 mg/die omeprazole; then the proton pump inhibitors (PPI) dose was 20 mg/die. Endoscopic and histologic controls have been performed every 6 months. The study considered the fìrst 32 patients who completed at least 24 months of follow-up, whose median was 49.5 months (range: 24-60).

RESULTS

The ablation of BE was achieved with a median of 2.0 APC sessions, without side- effects. The recurrence of SIM (specialized intestinal metaplasia) was detected in 3 patients, while nor dysplasia or cancer developed.

CONCLUSIONS

Our results confirm that APC can lead both to eradication of BE and the restoration of squamous epithelium. As recent reports indicated the persistence of SIM beneath the new epithelium and even a neoplastic growth (adenocarcinoma) in the treated area, despite APC, 2 questions have arisen: is APC unable to radically ablate BE or on the contrary are these findings due to defects of the ablative technique needing improvement? To settle more precise conclusions, further investigation with larger numbers of patients and for longer follow-up is required.