Colo-rectal endoscopic full-thickness resection (EFTR) with the over-the-scope device (FTRD®): A multicenter Italian experience.

BACKGROUND AND AIM: Endoscopic full-thickness resection(EFTR) with FTRD® in colo-rectum may be useful for several indications.The aim was to assess its efficacy and safety. MATERIAL AND METHODS: In this retrospective multicenter study 114 patients were screened; 110 (61M/49F, mean age 68 ±â€¯11 years, range 20-90) underwent EFTR using FTRD®. Indications were:residual/recurrent adenoma (39), incomplete resection at histology (R1 resection) (26), non-lifting lesion (12), adenoma involving the appendix (2) or diverticulum (2), subepithelial lesions(10), suspected T1 carcinoma (16), diagnostic resection (3). Technical success (TS: lesion reached and resected), R0 resection (negative lateral and deep margins),EFTR rate(all layers documented in the specimen) and safety have been evaluated. RESULTS: TS was achieved in 94.4% of cases. EFTR was achieved in 91% with lateral and deep R0 resection in 90% and 92%. Mean size of specimens was 20 mm (range 6-42). In residual/recurrent adenomas, final analysis revealed: low-risk T1 (11), adenoma with low-grade dysplasia (LGD) (24) and high-grade dysplasia (HGD) (3), scar tissue (1). Histology reports of R1 resections were: adenoma with LGD (6), with HGD (1), low-risk (6) and high-risk (1) T1, scar tissue (12). Non-lifting lesions were diagnosed as: adenoma with HGD (3), low-risk (7) and high risk (2) T1. Adverse clinical events occurred in 12 patients (11%),while adverse technical events in11%. Three-months follow-up was available in 100 cases and residual disease was evident in only seven patients. CONCLUSIONS: EFTR using FTRD® seems to be a feasible, effective and safe technique for treating selected colo-rectal lesions. Comparative prospective studies are needed to confirm these promising results.

Two cases of colon LST in transplanted liver patients.

Long-life immunosuppressive therapy increases the risk of de novo tumors in liver transplant recipients by decreasing the immune surveillance against malignant cells and oncogenic viruses. However, no cases of colon precancerous lesions have been reported in these subjects. Patient n. 1, a 73 yrs old male treated with calcineurin and purine synthesis inhibitors, showed at a per-protocol colono-scopy a 3 cm laterally spreading tumor (LST). Patient n. 2, a 73 yrs old male treated with calcineurin inhibitors, showed at a screening colonoscopy an LST occupying one third of the lumen circumference. Both subjects were asymptomatic, had been transplanted 14 years before, and in both cases, lesions showed severe dysplasia. LSTs represent 17.2% of advanced colorectal neoplasia (CRC) and risk factors are multifactorial. Immunosuppression may play a role which is however not completely understood. Based on this report, surveillance colonoscopy in liver transplanted patients should be considered.

Central and Mucosal Immunities are Modified by Non Adsorbable Antibiotic Treatment in Uncomplicated Diverticular Disease.

We review our experience on Rifaximin in uncomplicated diverticular disease. Our data show that a 2 week treatment induces modifications in the immune system: local mucosal lymphocytes with TLR-4 were increased. In the peripheral blood CD103 cells, which increased before treatment, returned to normal values after Rifaximin.

Clinical indications for computed tomographic colonography: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline

This is an official guideline of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR). It addresses the clinical indications for the use of computed tomographic colonography (CTC). A targeted literature search was performed to evaluate the evidence supporting the use of CTC. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. ESGE/ESGAR do not recommend barium enema in this setting (strong recommendation, high quality evidence). 2 ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. Delay of CTC should be considered following endoscopic resection. In the case of obstructing colorectal cancer, preoperative contrast-enhanced CTC may also allow location or staging of malignant lesions (strong recommendation, moderate quality evidence). 3 When endoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with symptoms suggestive of colorectal cancer (strong recommendation, high quality evidence). 4 ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp  ≥  6  mm in diameter detected at CTC. CTC surveillance may be clinically considered if patients do not undergo polypectomy (strong recommendation, moderate quality evidence). 5 ESGE/ESGAR do not recommend CTC as a primary test for population screening or in individuals with a positive first-degree family history of colorectal cancer (CRC). However, it may be proposed as a CRC screening test on an individual basis providing the screenee is adequately informed about test characteristics, benefits, and risks (weak recommendation, moderate quality evidence).

Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline.

BACKGROUND AND AIM: This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the choice amongst regimens available for cleansing the colon in preparation for colonoscopy. METHODS: This Guideline is based on a targeted literature search to evaluate the evidence supporting the use of bowel preparation for colonoscopy. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence. RESULTS: The main recommendations are as follows. (1) The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). (2) The ESGE recommends a split regimen of 4 L of polyethylene glycol (PEG) solution (or a same-day regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation, high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence). (3) The ESGE advises against the routine use of sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence).

Complete transmural gastric migration of PTFE mesh after surgery for a recurrent hiatal hernia.

Complications directly associated with the use of prosthetic materials in large hiatal hernia repair are rarely cited events in the literature. We herein report a case of a 47 year-old woman who came to our attention for a subacute onset of severe dysphagia and weight loss. She previously underwent laparotomic Nissen fundoplication with PTFE dual-mesh cruroplasty for a large recurrent hiatal hernia. With the clinical suspicious of "Tight Nissen", an endoscopy was performed and revealed a circular stenosis in the lower esophagus, a rotation of the stomach and, surprisingly, the presence of PTFE mesh free-moving in the gastric lumen With the use of rattooth forceps, the foreign body was removed and, after few days, the patient underwent a surgical debridement of hiatal scar tissue and a gastropexy procedure. In conclusion, dysphagia may manifest during the early postoperative period after mesh repair antireflux surgery, but such dysphagia usually resolves; if it doesn't or if it worsens, mesh migration must be excluded.

Detecting microcalcifications in atherosclerotic plaques by a simple trichromic staining method for epoxy embedded carotid endarterectomies.

Atherosclerotic plaques have a high probability of undergoing rapid progression to stenosis, becoming responsible of acute coronary syndrome or stroke. Microcalcifications may act as enhancers of atherosclerotic plaque vulnerability. Considering that calcifications with a diameter smaller than 10 mm in paraffin embedded tissue are rather difficult to detect, our aim was to analyze microcalcifications on semithin sections from epoxy resin embedded samples of carotid endarterectomies using an original trichromic stain (methylene blue--azur B--basic fuchsine--alizarin red). We have compared samples stained either with our method, methylene blue-azur B alone or with Von Kossa staining, and methylene blue-azur B -basic fuchsine alone or with Von Kossa staining. Our method resulted to be simple and fast (ca. 2 min), it gives a sharp general contrast for all structures and allows to easy identify collagen and elastin. In addition, gray-green colour associated to intracellular lipid droplets evidences foam cells, which are particularly abundant in endarterectomies samples. Mast cells and their metachromatic granules are also well recognized. Calcifications over 0,5 mm are clearly recognizable. In conclusion, microcalcifications are clearly distinguished from the extracellular matrix in spite of their reduced dimensions. Methylene blue--azur B--basic fuchsine--alizarin red method is easy to use, reproducible, and is particularly suitable for the identification of microcalcifications in the morphological analysis of atherosclerotic plaques.

Review article: uncomplicated diverticular disease of the colon.

Diverticular disease of the colon is the fifth most important gastrointestinal disease in terms of direct and indirect health care costs in western countries. Uncomplicated diverticular disease is defined as the presence of diverticula in the absence of complications such as perforation, fistula, obstruction and/or bleeding. The distribution of diverticula along the colon varies worldwide being almost always left-sided and directly related to age in western countries and right-sided where diet is rich in fibre. The pathophysiology of diverticular disease is complex and relates to abnormal colonic motility, changes in the colonic wall, chronic mucosal low-grade inflammation, imbalance in colonic microflora and visceral hypersensitivity. Moreover, there can be genetic factors involved in the development of colonic diverticula. The use of non-absorbable antibiotics is the mainstay of therapy in patients with mild to moderate symptoms, and the effect of fibre-supplementation alone does not appear to be significantly different from placebo, although no definite data are available. More recently, alternative treatments have been reported. Mesalazine acts as a local mucosal immunomodulator and has been shown to improve symptoms and prevent recurrence of diverticulitis. In addition, probiotics have also been shown to be beneficial by re-establishing a normal gut microflora. In this study, the current literature on uncomplicated diverticular disease of the colon is reviewed.

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.

Stenting in esophageal strictures.

The interventional management of esophageal strictures remains, to date, an important clinical challenge. Stenting is probably the best palliation modality in patients with incurable esophagogastric carcinoma. Conversely, the use of esophageal stents is still relatively uncommon for the treatment of refractory benign strictures. In the last few years, several new stents have become available as a result of significant advances that have been made in terms of design and materials. This review focuses on the endoscopic use of esophageal stents in malignant and benign esophageal strictures, revisiting the different types of expandable stents presently available, the techniques, the results, and the complications of stent insertion and giving some practical advices. Future developments in the field of esophageal stenting are also discussed.

A modified laryngeal mask in the endoscopic management of an esophageal tumor.

The laryngeal mask airway (LMA) can be used for gastroscopy, but its use can result in loss of the seal and/or displacement of the cuff. We describe an LMA that was specifically modified for gastroscopy and report its use in a patient with an esophageal tumor. The modified LMA has (a) a second tube that allows instruments to be directed toward the esophagus and (b) a second cuff mounted on the dorsal surface that increases the efficacy of the seal with the larynx. A 78-year-old man weighing 65 kg presented with a large mediastinal adenocarcinoma that was infiltrating the lateral wall of the thoracic esophagus. An esophagoscopy under anesthesia was planned to debulk the tumor. The modified LMA was inserted easily following induction with propofol. Anesthesia was maintained with propofol and 50% O2 in air and spontaneous ventilation. A lubricated 10.5-mm external diameter gastroscope was inserted into the second tube and passed easily into the esophagus. The tumor was successfully debulked using a polypectomy snare and an argon plasma coagulator. There was no loss of seal or displacement of the cuff, and the patient was stable throughout the procedure. We conclude that gastroscopy is feasible with the modified LMA. The device has a potential application in patients who require ventilatory support during gastroscopy.

[Endoscopic treatment of benign esophageal stenosis]. / Il trattamento endoscopico delle stenosi esofagee benigne.

Benign esophageal stenosis is the most frequent type of stenosis of the digestive tract. Surgical treatment is still affected by a high percentage of morbidity and mortality. This is not acceptable for a condition which is not neoplastic in nature. The introduction of modern endoscopic instruments has significantly simplified the technique also reducing the complications, therefore oesophageal dilatation has a fundamental role. The main indications to endoscopic treatment are represented by postoperative stenosis, and those caused by caustics, peptic acid, actinic lesions and achalasia. During the past 15 years, the Authors performed 205 endoscopic dilatation including 26 cases affected by esophageal achalasia. In the experience of the Authors, olivarian metallic probes were gradually abandoned in favour of Celestin & Savary polimetric dilators while pneumatic dilators were preferred only in achalasic cases. Endoscopic therapy was resolutive in 24 patients affected by achalasia (92.3%). In 158 patients, mechanic dilatation was employed (88.2%) and among them, 4 cases (2.19%) of esophageal perforation were observed. Overall, mortality rate was zero. As far as the average number of dilatation employed, the highest number was registered among caustic lesions (5), followed by peptic (4), and post-operative stenosis (1). The results obtained confirm the validity and efficacy of the endoscopic treatment for benign esophageal stenosis also considering the good compliance of the patients and the fact that no general anaesthesia is required.

[Results of the local excision of rectal cancer after high-dose radiotherapy associated or not to chemotherapy]. / Risultati dell'escissione locale del cancro del retto dopo radioterapia ad alte dosi associata o meno a chemioterapia.

Local excision of rectal cancer in low-risk patients is appealing but it provides limited control of the disease. Postoperative radiation therapy may improve results. The Authors report on their experience with preoperative high dose radiation therapy for rectal cancer patients; more recently, chemoradiation was used. Local excision is advised only for those patients with minimal or no residual disease. The results obtained in 34 cases are encouraging; moreover, a better control of the disease seems to be offered combining chemo- and radiotherapy.

[Endolaparoscopic "Rendez-vous" in the treatment of cholecysto-choledochal calculosis]. / Il "Rendez-vous" endolaparoscopico nel trattamento della calcolosi colecisto-coledocica.

Different methods, all of which equally efficacious and safe, can be selected to access the choledochus in patients with cholecysto and choledocholithiasis on the basis of clinical and anatomosurgical parameters. From 1990 we evaluated three groups of patients who underwent surgery at different times and with different methods: sequentially (endoscopic sphincterotomy and laparoscopic cholecystectomy), one step laparoscopy and combined laparo-endoscopy. The results obtained seem to show that the treatment with laparoscopy alone is the most advantageous in terms of cost-benefit, while the endoscopic access of the choledochus during laparoscopic cholecystectomy is the one to prefer in terms of efficacy and safety.

[Malignant peritoneal mesothelioma: apropos a new case]. / Il mesotelioma peritoneale maligno: a proposito di una nuova osservazione.

Prognosis for patients with malignant peritoneal mesothelioma is very poor, and most patients are beyond cure by the time the diagnosis has been made. The pathogenesis of this uncommon neoplasm seems to be related to asbestos and radiation exposure. The authors report a case of diffuse peritoneal mesothelioma in a 33-year-old man. Since the patient complained of aspecific symptoms and both biochemical and "imaging" studies did not provide useful informations for a definitive diagnosis, an exploratory laparotomy was performed. Intraoperative histological findings demonstrated the presence of a malignant peritoneal mesothelioma which had spread all over the omentum; considering the inoperability assessment of this case, the operation was completed and the patient was dismissed with an adjuvant chemo-therapy. Five weeks later the patient died.