Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study.

BACKGROUND: The necessity for drainage of both liver lobes in tumors arising at the biliary bifurcation is controversial. The aim of this study was to compare the outcome of unilateral versus bilateral drainage in patients with biliary obstruction at the hilum. METHODS: One hundred fifty-seven consecutive patients with primary cholangiocarcinoma, gallbladder cancer, or periportal lymph node metastases were randomly allocated to unilateral (group A) or bilateral (group B) hepatic duct drainage. RESULTS: In intention-to treat analysis, group A had a significantly higher rate of successful endoscopic stent insertion than group B (88.6% vs. 76.9%, p = 0.041). Group B had a significantly higher rate of complications than group A (26.9% vs. 18.9%, p = 0.026) because of the higher rate of early cholangitis (16.6% vs. 8.8%, p = 0.013). In per-protocol analysis the rate of successful drainage, complications, and mortality did not differ between the two groups. Median survival did not differ between the two groups but was significantly different for patients with cholangiocarcinoma and those with gallbladder cancer versus patients with metastatic tumors (p = 0.0247). CONCLUSION: The insertion of more than one stent would not appear justified as a routine procedure in patients with biliary bifurcation tumors.

Endoscopic stenting for definitive treatment of irretrievable common bile duct calculi. A long-term follow-up study of 49 patients.

BACKGROUND/AIMS: The value of endoprostheses for long-term management of bile duct stones has not been formally established. A prospective evaluation of results and complications of the insertion of biliary endoprostheses was performed in patients with endoscopic irretrievable bile duct stones. METHODOLOGY: From January 1990 to September 1998, 49 patients (18 men and 31 women; average age 75.5 years), underwent endoscopic biliary stenting for endoscopically irretrievable bile duct stones. RESULTS: Successful biliary drainage was achieved in all patients. Early complications occurred in 12.2% of cases. Over the long-term follow-up (median follow = 39 months) late complications occurred in 40.8% of cases, with 3 cases of biliary-related death. CONCLUSIONS: For immediate bile duct drainage, endoprostheses proved a safe and effective alternative for treatment of patients with endoscopically irretrievable bile duct stones. Because of the risk of subsequent complications, its use as a definitive treatment should be confirmed to highly selected cases.

Distally migrated esophageal self-expanding metal stents: wait and see or remove?

BACKGROUND: Extraction of a migrated esophageal stent may be extremely difficult with a substantial risk of complications including esophageal perforation and hemorrhage. METHODS: Retrospectively 242 patients were evaluated who underwent implantation of self-expanding metal stents (SEMS) and 13 (5.4%) were identified with distal stent migration. In all cases of stent dislocation into the stomach, extraction of the stent was not attempted and a new stent was inserted. RESULTS: Twelve patients had dysphagia. One patient underwent surgery because of stent impaction in the colon, 3 had unrecognized passage of the stent per rectum, and 9 had evidence of the stent into the stomach. Further severe complications were not observed in any patient and all stents remained into the stomach. CONCLUSION: Complications arising from migrated esophageal stents are uncommon. Further studies are warranted to determine which patients with migrated SEMS warrant stent retrieval.

Secondary aortoduodenal fistula. Rare endoscopic finding in the course of digestive hemorrhage.

Secondary aortoduodenal fistula is a rare and life-threatening long-term complication of abdominal aortic surgery. Pathogenesis is often not clear; both mechanical trauma and septic procedures are involved as principal factors. The interval between first intervention and development of the fistula can vary from months to years. The presentation is often subtle with a herald bleeding followed by a period of grace, followed or not by an exsanguinating hemorrhage. The right diagnosis of aortoduodenal fistula hemorrhage can be difficult. We emphasize the need to have an early and correct diagnosis in one with differential diagnosis of patients with gastrointestinal bleeding after previous abdominal aortic replacement surgery. The esophagogastroduodenoscopy (until the Treitz) is the main diagnostic procedure, able to demonstrate the fistula and rule out other possible causes of bleeding.

[Results of the use of endoprostheses in the treatment of retained common bile duct stones]. / Risultati dell'utilizzo di protesi per via endoscopica nel trattamento della litiasi difficile della via biliare principale.

BACKGROUND: The value of endoprostheses for long term management of bile duct stones has not been formally established. A retrospective evaluation of results and complications of the insertion of biliary endoprostheses was performed in patients with endoscopic irretrievable bile duct stones. METHODS: From January 1990 to September 1999, 52 patients (19 men and 33 women; average age 76 years), underwent endoscopic biliary stenting for endoscopically irretrievable bile duct stones. RESULTS: Successful biliary drainage was achieved in 50/52 (96.1%) patients. Early complications occurred in 11.5% of cases. Over the long term follow-up (average follow-up = 39.5 months) late complications occurred in 40.8% of cases, with 3 cases of biliary-related death. CONCLUSIONS: For immediate bile duct drainage, endoprostheses proved a safe and effective alternative for treatment of patients with endoscopically irretrievable bile duct stones. Because of the risk of subsequent complications, its use as a definitive treatment should be confirmed to highly selected cases.

Stenting or surgery for treatment of irretrievable common bile duct calculi in elderly patients?

BACKGROUND: The value of endoprostheses for long-term management of bile duct stones has not been formally established. We retrospectively compared the results of this method versus surgical approach in elderly patients (>70 years) with endoscopically irretrievable bile duct stones. METHODS: From January 1990 to September 1998, 68 patients over 70 years old underwent endoscopic biliary stenting (group A: 31 patients) or surgery (group B: 37 patients) for endoscopically irretrievable bile duct stones. The groups were similar with regard to gender, age, clinical presentation, ASA score, and number and size of the stones. RESULTS: Successful biliary drainage was achieved in 31 of 31 patients of group A and 37 of 37 patients of group B. Early complications occurred in 12.9% of group A versus 29.7% of group B (P <0.005) and early mortality was 0% in group A versus 2.7% of group B (P = NS). Over the long-term follow-up, late complications occurred in 35.5% of group A versus 8.1 % of group B (P <0.001). Three cases of biliary-related death occurred in group A versus 0 in group B (9.6% versus 0%: P <0.005). CONCLUSIONS: For immediate bile duct drainage endoprostheses proved a safe and effective alternative to surgery in elderly patients with endoscopically irretrievable bile duct stones. Because of the risk of subsequent complications, their use as a definitive treatment should be restricted to highly selected cases.

Prevalence of HNPCC in a series of consecutive patients on the first endoscopic diagnosis of colorectal cancer: a multicenter study. The Italian Collaborative Group.

BACKGROUND AND STUDY AIMS: It is difficult to measure the prevalence of hereditary non-polyposis colorectal cancer (HNPCC) in geographical areas that do not have tumor registers, as is the case in the present study, and it was therefore decided to assess the prevalence in Italy using different methods. PATIENTS AND METHODS: The pedigree was established for 485 of 501 colorectal cancer patients diagnosed with colorectal carcinomas. Patients were included consecutively in 13 gastroenterology centers; they had not taken part in prevention examinations. Information was collected regarding the neoplastic pathology observed in the families, confirmed in 90% of cases among 3515 first-degree relatives and in 79.5% of cases among 7068 second-degree relatives. RESULTS: In the 3515 first-degree relatives (1002 parents, 1560 siblings and 953 children), 61 colorectal carcinomas, 29 carcinomas in the digestive tract outside the colon, and 99 carcinomas in other locations were reported. Only five of the 485 patients (1%) satisfied the Amsterdam criteria (three cancers, two of which were in first-degree relatives in different generations and one in a relative younger than 50). When broadening the criteria that we are proposing (satisfying only two of the three Amsterdam criteria), the prevalence would increase to 3% (15 cases). CONCLUSIONS: Modifying the criteria makes it easier to identify new mutations or confirm the existence of those already known, as well as allowing preventative treatment in relatives who are apparently healthy.

[The palliation of dysphagia secondary to esophageal-cardial carcinoma with self-expandable metal prostheses. The authors' personal experience with 92 patients]. / La palliazione della disfagia secondaria a carcinoma esofago-cardiale con protesi metalliche autoespandibili. Esperienza personale su 92 pazienti.

BACKGROUND: Endoscopic insertion of a stent is an important option in the palliative management of esophageal obstruction and esophagorespiratory fistula. Plastic stents have been available for over 20 years. A new class of self-expanding metal stents for palliation of esophageal and cardial cancer is now available. METHODS: Between September 1992 and October 1997, 92 patients underwent implantation of self-expanding metal stents for palliation of dysphagia due to inoperable esophageal or cardial cancer (65 patients) or for locally recurrent carcinoma after surgery (12 patients), laser-therapy (11 patients) or radiotherapy (4 patients). RESULTS: Successful stent implantation was achieved in 89/92 patients (96.7%). After stent implantation the dysphagia score improved from 3.0, on average, to 0.5, on average. Early complications were observed in 4.5% and peroperative mortality was 2.1%. Late complications were observed in 25.6%, with a mortality rate of 1.1%. The mean survival time was 6.9 months. CONCLUSIONS: Self-expanding metal stents are a new effective alternative for palliation of dysphagia due to esophageal and cardial cancers.

Use of corticosteriods in the prevention of post-ERCP pancreatitis: results of a controlled prospective study.

OBJECTIVE: The aim of this prospective controlled study was to determine whether prophylactic corticosteroids decrease the incidence of post-ERCP pancreatitis. METHODS: A double-blind comparison of hydrocortisone (100 mg by i.v. infusion immediately before endoscopy) with placebo (sodium chloride administered in the same fashion). A total of 535 patients (286 women and 249 men, with an average age of 58.6 yr) who were scheduled to undergo diagnostic or operative ERCP underwent randomization. Six patients were excluded from the final evaluation for various reasons. The remaining 529 patients, 263 in the hydrocortisone group and 266 in the placebo group, were analyzed. Patients were divided into subgroups with regard to high risk factors for acute pancreatitis after ERCP. RESULTS: The overall incidence of acute pancreatitis was 5.3% (28 of 529 patients). Procedure-induced pancreatitis occurred in 15 of 263 (5.7%) patients treated with hydrocortisone and in 13 of 266 (4.9%) patients treated with placebo (p = NS). The results of analysis of risk factors for pancreatitis did not evidence any significant difference between the hydrocortisone group and the placebo group. CONCLUSIONS: Hydrocortisone does not prevent acute pancreatitis after diagnostic or therapeutic ERCP.

Impact on the quality of remaining life of treatment with self-expandable metal prostheses in patients with inoperable esophago-cardial cancer. Results of a study of 107 consecutive patients treated with Ultraflex-type prostheses.

BACKGROUND: Self-expanding metal stents are a new alternative for palliation of esophagocardial malignancies. We evaluated the impact of these stents on the quality of remaining life in patients affected by inoperable esophago-cardial cancer. METHODS: Between September 1992 and September 1997, 102 patients underwent implantation of self expanding metal stents for palliation of dysphagia due to esophagene or cardial cancer (76 patients), or for locally recurrent carcinoma after surgery (14 patients), lasertherapy (13 patients) or radiotherapy (5 patients). Stents were implanted under radiological and endoscopic control in patients under mild sedation. RESULTS: Successful stent implantation was achieved in 102/107 patients (95.3%). Early complications were observed in 4.9% and per-operative mortality was 1.96%. After stent implantation the dysphagia score improved from 3.0, on average, to 0.5, on average. Late complications were evidenced in 25.5%. Weight gain was evidenced in 24.5% and the performance status improved in 14.3%. The mean survival time was 6.9 months. CONCLUSIONS: Self expanding metal stents are an effective alternative for palliation of malignant dysphagia due to esophageal and cardial cancers.

Endoscopic and surgical palliation of esophageal cancer.

BACKGROUND: Esophageal carcinoma is frequently diagnosed at an advanced stage. Therefore for most patients either surgical or endoscopic palliation with or without radiochemotherapy may be taken into consideration. This retrospective study analyzes immediate and long term results of perendoscopic treatment in patients with unresectable esophageal cancer. Moreover a comparative analysis has been made with a group of patients who underwent palliation surgery. METHODS: From 1982 to 1998 458 patients with esophageal cancer underwent palliation perendoscopic disobstructive treatment (427 patients), palliation surgery (29 patients) and dis-obstruction followed by perendoscopic gastrostomy (2 patients). Among patients treated by perendoscopic procedures, 18 underwent dilation, 53 dilation and radiotherapy, 236 stent implantation, respectively of the plastic (102) and self-expandable metallic (134) type. 120 patients underwent NdYAG laser treatment. RESULTS: The results for patients who underwent perendoscopic procedures are referred to as regards the first 30 days after treatment and on the long run in terms of grade of dysphagia according to Visick's scale. For the group of patients undergoing simple dilation we had an improvement (from Visick III-IV to I-II) in 33% of cases and in 54.7% when radiotherapy was added. Far better results were achieved in all groups undergoing stent implantation, with or without brachytherapy, and NdYAG laser treatment with or without previous chemical necrolysis (range 90.3-100%). Most frequent complications were obstruction and stent displacement. Mean survival was better for patients undergoing laser recanalisation (7.2 months) while among stents the metallic type has given better results than plastic ones both for survival (6.2 vs 5.9 months) and mortality (2.4 vs 4.9%). Comparison with the group undergoing palliation surgery has shown that mean survival is the same for patients undergoing jejunostomy or gastrostomy while it is significantly better for patients undergoing palliation resection or by-pass surgery compared with those treated by stent implantation or laser recanalisation. CONCLUSIONS: The palliation treatment of patients with esophageal and cardial carcinoma is still a complex problem as far as therapeutic strategy is concerned. The best palliation is surgery even though characterized by a greater morbidity and mortality compared with perendoscopic techniques that may represent, in selected cases, a suitable alternative.

[Endoscopic palliation of dysphagia due to anastomotic recurrences after esophageal surgery and total gastrectomy due to carcinoma]. / La palliazione endoscopica della disfagia secondaria a recidiva dell'area anastomotica dopo resezione esofagea e gastrectomia totale per carcinoma.

BACKGROUND: Dysphagia is the main symptom of locally recurrent esophageal and gastric carcinoma and generally suggests extensive disease. The safety and efficacy of endoscopic palliation in patients who developed locally recurrent disease after surgery is evaluated. METHODS: Twenty-six males and 12 females, with an average age of 63.5 years were included in the patients group. In 12 patients there was an esophago-gastric anastomosis, in 26 an esophago-jejunostomy, after total gastrectomy. Anastomotic recurrences were divided into predominantly polypoid (16 cases) and predominantly stenosing (22 cases). Three treatment modalities were employed: endoscopic dilation (6 cases), Nd-Yag laser therapy (16 cases) and prostheses (16 cases). RESULTS: Successful endoscopic treatment was obtained in 33 out of 38 patients (86.8%). Major complications occurred in 5 patients (15%) with a mortality rate of 6%. CONCLUSIONS: The endoscopic palliation is effective. Technically, endoscopic treatment is easier to perform, with better results, when dealing with polypoid rather than stenosing recurrences.

Laparoscopic cholecystectomy (LC), intraoperative endoscopic sphincterotomy (ES), and common bile duct stones (CBDS) extraction for management of patients with cholecystocholedocholithiasis.

BACKGROUND: A combined method of endoscopic sphincterotomy (ES) with common bile duct stone (CBDS) extraction and laparoscopic cholecystectomy (LC) under general anesthesia for a single-session treatment of patients with colecysto-choledocholithiasis is described. METHODS: From June 1994 to January 1995, 15 consecutive cases considered for elective LC with preoperative diagnosis of CBDS underwent this procedure. Following orotracheal intubation, the patient is turned on the left lateral decubitus for ES and CBDS extraction. Nasobiliary drainage is positioned for per-laparoscopic cholangiogram. Routine LC is finally performed. RESULTS: These two interventions were successfully accomplished in all patients. Mean duration of the operative time for the combined procedure was 97.7 +/- 30.4 min, range 60-140 min. In four (26.6%) cases an accessory trocar with retracting instrument was used to obviate the bowel distension. CONCLUSIONS: No complications of ES or LC were observed. Mean hospital stay was 3 days (range 2-5 days). Routine follow-up (mean 3 +/- 2 months, range 1-12 months) did not reveal biliary-related problems in any of the observed patients.

Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study.

BACKGROUND: Rapid palliation of malignant dysphagia is usually possible with endoscopic implantation of a plastic prosthesis, but this device has a high rate of complications. Recently, expandable metal stents, a new class of endoprosthesis, have become available and may reduce complication rates. METHODS: Thirty nine patients affected by esophageal thoracic cancer were randomly assigned to treatment with either a plastic stent (20 patients) or expandable metal stent (19 patients). The degree of palliation (expressed as dysphagia score) and incidence of complications (short- and long-term) were compared in both treatment groups. RESULTS: Technical success, as a percentage of successful intubation, was similar in both treatment groups (90% vs 94.7%, p = NS) and dysphagia scores improved significantly and similarly in both treatment groups. Nevertheless, complications and mortality related to implantation were significantly less frequent with metal stents than with plastic prostheses (complications: 0% vs 21%, p < 0.001; mortality: 0% vs. 15.8%, p < 0.001). Late complications included obstruction by food in both treatment groups (four cases with plastic stents vs four cases with metal stents), tube migration only with plastic prostheses (two cases) and tumor ingrowth only with metal stents (two cases). CONCLUSIONS: Expandable metal stents can be considered an effective and safer alternative to conventional plastic prostheses in the treatment of esophageal obstruction caused by inoperable cancer.

[The current status of the perendoscopic treatment of biliary lithiasis]. / Lo stato attuale del trattamento perendoscopico della litiasi biliare.

The role of therapeutic biliary endoscopy, for management of bile duct stones, continues to be defined. Actually the endoscopic management should be considered the procedure of choice for treatment of retained or recurrent stones of the main bile duct, gallstone pancreatitis an acute cholangitis. It's role in the era of laparoscopic cholecystectomy is evolving. Actually new techniques and accessories continue to be developed for treatment of bile duct stones. The problem of the difficult bile duct stones has essentially been solved by the development of a variety of lithotripsy techniques. This work focuses on new developments in the therapeutic biliary endoscopy for treatment of main bile duct stones.

[Results of endoscopic Nd-Yag laser treatment of inoperable colorectal carcinoma]. / Risultati del trattamento perendoscopico con Nd-YAG laser del carcinoma del colon-retto non operabile.

Between November 1986 and December 1993, 94 patients underwent endoscopic laser therapy for inoperable colo-rectal cancers. According to the main clinical symptoms, tumors were divided into obstructing and bleeding; A Nd-YAG non contact laser was used at power setting of 70 to 100 watt. In 28 cases laser therapy was carried out after electrorection of the tumor and in 22 cases after dilation; in 41 cases it was associated with radiation therapy. In 90% of bleeding tumors and in 70% of obstructing tumors we achieved a good result in the short term. In 50% of bleeding tumors and in 65% of obstructing tumors the symptoms recurred after an interval of 8.2 and 6.1 weeks. The main survival period was 11.2 months for bleeding tumors and 7.4 months for obstructing tumors. Two patients with a small rectal cancer are free to neoplasia at 19 and 26 months after laser therapy.

Self-expanding metal stents for palliation of inoperable carcinoma of the esophagus and gastroesophageal junction.

OBJECTIVES: Rapid palliation of malignant dysphagia is usually possible with endoscopic implantation of plastic prosthesis, but this device has a high rate of complications. Recently expandable metal stents have become available that may have a reduced complications rate. METHODS: This report details our experience with 32 patients treated from September of 1992 through June of 1994. Twenty-three patients were treated primarily with the Ultraflex esophageal prosthesis, and five patients were treated with postoperative malignant stricture, three with failed laser therapy and one with postradiation therapy malignant stricturing. Implantation was successful in 30/32 patients (94%). No major bleeding or perforation followed placement. The dysphagia score improved dramatically from 3 to 0.5. Twenty-six patients had a follow-up of at least 30 days. No stent migration occurred. Food impaction was seen in three patients, tumor ingrowth in three, and overgrowth in one patient. The median survival was 6.2 months with a range of 1.8-11.3 months. CONCLUSIONS: Expandable metal stents are effective and safe for palliation of malignant obstruction of the esophagus and gastro-esophageal junction. However, long term problems remain to be addressed, such as ingrowth by tumor, food impaction, and limitation of stent expansion by tumor rigidity.

Laparoscopic cholecystectomy in obese patients compared with nonobese patients.

Obese patients treated by laparoscopic cholecystectomy currently appear to be the largest risk subgroup amenable to consistent scientific evaluation. Here we report our experience and compare the results in obese patients with those obtained in nonobese patients undergoing the laparoscopic procedure. Laparoscopic cholecystectomy in obese patients was technically more difficult with significantly longer operating time (p < 0.01), but intraoperative and postoperative technical complications were not significant in the groups analyzed. Obese patients present significant anesthesiological complications (p < or = 0.001). The results of this experience and the literature review indicate that the therapeutic advantages proved in nonobese patients can be extended to the obese population.