Use of robotic colonoscopy in patients with previous incomplete colonoscopy.

OBJECTIVE: Conventional colonoscopy (CC) is the gold standard to diagnostic and therapeutic approach to colon. However, in few cases, cecal intubation could fail due to colon anatomy, patient compliance and physician expertise. Endotics robotic colonoscopy is a novel, safe, mini-invasive modality to explore the entire colon. Our aim was to assess, in a retrospective study, Endotics ability of cecal intubation in all cases in which CC failed. PATIENTS AND METHODS: Between January 2008 and December 2012, 276 Endotics robotic colonscopy examinations were performed at the Gastroenterology and Metabolic Diseases Unit of Pisa University Hospital, Pisa, Italy, in a series of consecutive patients who had undergone CC and failed cecal intubation. RESULTS: We assessed the cecal intubation rate in 102 patients addressed to Endotics after previous incomplete CC. Overall, endotics system was successful in 93.1% of the incomplete conventional colonoscopy cases (95% performance). CONCLUSIONS: Whenever the intended exploration of the entire colon with CC failed, the endotics robotic endoscopy represented a useful tool as it helped examine the entire colon in almost all cases.

Quality control of sedation for diagnostic radiological procedures in paediatric patients (waiting for guidelines).

BACKGROUND: The number of children requiring sedation for radiological procedures is increasing. Anaesthesiologists are increasingly involved in giving sedation or general anaesthesia in the rooms of the Radiology Department. This activity is not easy, and can be dangerous. The procedure is often performed on an ambulatory basis, so the child must be alert and discharged rapidly after the procedure. METHODS: We reviewed the medical charts of 488 patients in order to evaluate the incidence of complications during deep sedation for diagnostic radiological procedures. The patients were sedated with intravenous thiopental or propofol, or with oral chloral hydrate. All the patients were breathing spontaneously and received only supplemental O(2). RESULTS: We found only a few cases of complications, immediately treated without any recourse to tracheal intubation: respiratory failure with arterial desaturation to 94%, regurgitation, vomiting and persistent cough. CONCLUSIONS: On the basis of our experience, we believe that deep sedation with endovenous drugs guarantees safety and rapid discharge after the procedure.

[Post-intubation subglottal stenosis in children: risk factors and prevention in pediatric intensive care]. / Stenosi sottoglottica postintubazione nel bambino. Fattori di rischio e possibilità di prevenzione in terapia intensiva pediatrica.

BACKGROUND: Endotracheal intubation (EI) may result in significant injury to the larynx and trachea; subglottic stenosis is the most dangerous consequence of this injury in the pediatric age. It is well known that there are potential risk factors for post-intubation subglottic stenosis, and namely the underlying disease requiring EI, the age and body weight at EI, the duration and number of EI, the absence of sedation and the occurrence of infectious, hypotensive or hypoxic events during the period of EI and the traumatic EI. On the basis of our data an attempt is made to understand which factors are more important in the pathogenesis of this complication and whether post-intubation subglottic stenosis is a preventable complication of EI in children. METHODS: The clinical records of 32 out of 35 children with post-intubation subglottic stenosis referred to our institution because of this complication in the period 1990-1997 (8 years) have been examined. Three children were excluded from the study because of partial data. Our surgical division is specialized in the diagnosis and the management of pediatric laryngotracheal diseases. The diagnosis was confirmed by videolaryngotracheoscopy under general anesthesia and by computerized tomography or magnetic resonance imaging in 10 children whose tracheal stenosis was critical. The degree of the stenosis was determined according to Cotton's classification. RESULTS: The analysis of our data confirms that post-intubation subglottic stenosis is a more frequent complication in infants and particularly in low birth weight infants. It occurred after long lasting EI, but after short lasting EI too. Many of the children observed had their trachea intubated several times during their illness and many EI were traumatic. Sedation during EI was only seldom took into account by pediatric intensivists. CONCLUSIONS: Prevention of post-intubation subglottic stenosis is possible through a better management of the EI and of the child with a tracheal tube. Sedation of intubated children and skill in the EI technique and in the tube size selection are very important. Many intubations can be avoided with a better attention to the tube fixation and to extubation criteria. Some children at high risk for this complication can be identified.

Colonic disease in cirrhotic patients with portal hypertension: an endoscopic and clinical evaluation.

Fifty cirrhotic patients with portal hypertension but without colonic or systemic disease underwent lower gastrointestinal endoscopy in order to investigate the effects, if any, of portal hypertension on the colon. Fifty patients without liver or systemic disease, examined by colonoscopy because of irritable bowel syndrome in the same period served as controls. Rectosigmoid varices were observed in 34% of the cirrhotic patients and 2% of the controls. Hemorrhoids were observed in 70% of the cirrhotic patients and 48% of the controls. Multiple vascular-appearing lesions were found in 16% of the cirrhotic patients and 6% of the controls. Nonspecific inflammatory changes were noted in 10% of the cirrhotic patients and 4% of the controls. Simultaneous presence, in the same patient, of rectosigmoid varices, hemorrhoids, multiple vascular-appearing lesions, and nonspecific inflammatory changes, was observed in only five (10%) of the cirrhotic patients. We found polyps in 12% of the cirrhotic patients and 14% of the controls, and a malignant tumor in 4% of the cirrhotic patients. The patients with normal colonoscopic findings were 8% of the cirrhotic patients and 36% of the controls. All patients and controls were followed up for 1 year; there was no gastrointestinal hemorrhage among controls, whereas 34% of the cirrhotic patients had an upper gastrointestinal hemorrhage (88% from esophageal varices, 12% from the stomach) and 4% had a lower gastrointestinal hemorrhage (one from rectosigmoid varices and one from nonspecific inflammatory lesions). Colonic lesions were significantly more frequent in the cirrhotic patients (92%) than in the control group (64%); however, such lesions did not seem specific to the disease and were not statistically correlated with the degree of esophageal varices by Child's grading, the etiology of cirrhosis, or the bleeding risk from the lower gastrointestinal tract.

Comparison among Different Types, Dosages and Duration of Interferon Therapy in Chronic Hepatitis C.

In an attempt to determine the best therapeutic protocol for the treatment of chronic hepatitis C with interferon (IFN), we reported our experience comparing the efficacy of IFN at the usual dose and duration, i.e. 3 million units (MU) three times weekly for 6 months, with the immediate and long-term effects of different types, dosages and duration of IFN therapy. 300 patients with chronic hepatitis C were randomly assigned to five groups of 60 subjects each and treated as follows: group A - recombinant IFN alpha (rIFNalpha) 3MU three times weekly for 6 months; group B - rIFNalpha 6MU three times weekly for 6 months; group C - rIFNalpha 3MU 3 times weekly for 12 months; group D - lymphoblastoid IFN (L-IFN) 6MU three times weekly for 6 months; group E - L-IFN 3MU three times weekly for 12 months. The diagnosis of hepatitis was based on clinical, serological and histological data in all patients. A 'biochemical response' was defined as the normalisation of alanine aminotransferase (ALT) values, and a 'complete response' as the normalisation of ALT with disappearance of serum hepatitis C virus (HCV)-RNA. A 'sustained response' was defined as the persistence of ALT normalisation and undetectable viraemia 2 years after the end of treatment. The five groups were homogeneous. The incidence of dropouts was 8%, and IFN treatment was interrupted for adverse effects in 11% of the patients. In group A, 55% of the patients showed a 'biochemical response' and 31% of the subjects demonstrated a 'complete response'. In group B, a 'biochemical response' was observed in 61% and a 'complete response' in 36% of the cases. In group C, 77% of the subjects showed a 'biochemical response', with a 'complete response' seen in 40%. In group D, we observed a 'biochemical response' in 55% of the patients and a 'complete response' in 33%. In group E, 79% of the subjects had a 'biochemical response', and a 'complete response' was seen in 38%. At the end of the treatment-free follow-up the percentage of patients with a sustained response was 24% in group A, 28% in group B, 35% in group C, 27% in group D and 33% in group E. Therefore, a longer period of IFN treatment seems to provide higher percentages of sustained response than the usual 6-month duration, independently of the type of IFN. Moreover, the patients treated with a higher dosage (6MU 3 times weekly) for 6 months showed a slightly better sustained response rate compared with the usual dose. In conclusion, even if the differences among the response rates in the five groups were not statistically significant, we recommend a 12-month regimen, possibly using higher dosages at least in the first 4 to 6 months of treatment.