A Pediatric Nasogastroscope Facilitates Colorectal Endoscopic Stenting.

PURPOSE: Endoscopic placement of self-expandable metal stents (SEMSs) to relieve malignant colorectal obstruction has been widely accepted in clinical practice. Despite increasing experience, early and late complications occur with an incidence ranging from 4% to 20%. MATERIALS AND METHODS: We have adopted a modification in the technique. A pediatric nasogastroscope (4.8 mm in diameter) has been used to pass the obstruction. It is possible to have a direct vision of the anatomy and pathology, and to pass the guidewire above the obstruction, through the nasogastroscope, under direct vision. Fluoroscopy was also used to follow the course of the guidewire and deployment of the stent. RESULTS: Early and late complications have been reduced with the new technique. CONCLUSIONS: In the most recent experience of 64 patients, early and late complications have been reduced significantly. This new technique reduces radiation exposure by 70% for the patients and for the operators.

Endoscopic Stenting for Colorectal Cancer: Lessons Learned From a 15-Year Experience.

GOAL: The aim of our prospective study was to analyze the results of endoscopic stenting to treat obstruction due to colorectal cancer and complications after colorectal resection for cancer. BACKGROUND: Endoscopic stenting for obstructing colorectal cancer has become a common place in clinical practice. However, there is a 2% to 5% risk of bowel perforation, and a percentage of technical failure of 2% to 10%. MATERIALS AND METHODS: In a 15-year period (August, 1999 to December, 2013), 153 patients with colorectal cancer had endoscopic placement of a self-expandable metal stent for treatment of an obstructing colorectal cancer (133 patients) or for treatment of complications after colorectal resection for cancer (20 patients). They were prospectively evaluated in a database and they form the basis of this report. RESULTS: There was no case of mortality or major morbidity. Overall technical success was 94.8%. After introducing the use of a pediatric nasogastroscope to pass the obstruction (71 patients), technical success was 100%. Complications in patients in whom the stent was left in place during the follow-up were frequent, requiring a close observation. We had 20 patients with fecal obstruction, 4 cases of stent dislodgment, and 8 cases of obstruction from ingrowth of the tumor. All patients were treated successfully endoscopically. CONCLUSIONS: Placement of self-expandable metal stents represents a valid technique. A proper training is required.

Review of a non-epithelial tumour of the small bowel after c-kit revolution.

UNLABELLED: In this article, we reviewed the case of a patient who was object, in 1999, of a published case report of schwannoma of the jejunal wall. Recently, the patient has been referred to our institution for a mass of the stomach identified by upper gastrointestinal endoscopy. The patient underwent a wedge resection of the stomach and a histopathological diagnosis of GIST of the stomach, based on a positive immunohistochemical staining of c-kit and CD34, was made. In consideration of these findings, we performed immunohistochemistry for c-kit and for CD34 on the previous lesion of the jejunal wall, which resulted strongly positive for CD117 and negative for CD34. A new diagnosis of gastrointestinal stromal tumour (GIST) of jejunal wall with moderate risk of progression was made. The lesion was also classified, according to the AJCC Seventh Edition, as a pT3, pN0, Stage II, GIST. This case shows the importance of a reassessment of the diagnosis of mesenchymal neoplasm of the small intestine made before the development of anti-CD117 antibody for a correct prognostic stratification, a better therapeutic management and a close follow-up, if necessary. KEY WORDS: Adjuvant therapy, c-kit, GIST Imatinib.

Endoscopic placement of self-expandable metallic stents for rectovaginal fistula after colorectal resection: a comparison with proximal diverting ileostomy alone.

BACKGROUND: Self-expandable metal stents can be used to treat patients with rectovaginal fistula after colorectal resection for cancer. METHODS: Fifteen patients with rectovaginal fistula, after colorectal resection for cancer, were treated with endoscopic placement of a self-expandable metal stent. In four patients, a diverting proximal stoma had been performed elsewhere. Mean age was 58 years. All patients had preoperative radiotherapy. In ten patients, the stent was placed as initial form of treatment. Four patients were referred after multiple failed operations. The control group consisted of ten patients who had rectovaginal fistula and underwent proximal diverting ileostomy and percutaneous drainage of the surrounding abscess RESULTS: One patient was not able to tolerate the stent, which was removed. At a mean follow-up of 22 months, the rectovaginal fistula healed in 12 patients. In the remaining two patients, the fistula has reduced significantly in size to allow a successful flap transposition. The fistula healed only in five out of the ten patients who had only a proximal ileostomy. CONCLUSIONS: Endoscopic placement of self-expandable metal stents represents a valid adjunctive to treat patients with rectovaginal fistula, after colorectal resection for cancer.

Association of liver steatosis with colorectal cancer and adenoma in patients with metabolic syndrome.

AIM: Metabolic syndrome has been identified as a risk factor for colorectal cancer and adenoma. The aim of our study was to assess the risk of colorectal cancer and adenoma in an adult Italian population with metabolic syndrome. PATIENTS AND METHODS: Ninety patients with metabolic syndrome were prospectively compared against a matched population without the syndrome to assess the prevalence of colorectal adenoma. Another 1,500 patients undergoing screening colonoscopy were prospectively analyzed: 134 patients with metabolic syndrome and colorectal adenoma were compared against a group of 108 patients with colorectal adenoma without metabolic syndrome to assess the prevalence of cancer. The study was performed from January 2008 until December 2010. Data were analyzed from March to June 2011. RESULTS: The prevalence of colorectal adenoma was twice as high in patients with metabolic syndrome. The incidence of cancer was higher in patients with colorectal adenoma and metabolic syndrome. Associated obesity and liver steatosis were the only factors with independent statistical value. CONCLUSION: Metabolic syndrome is a risk factor for adenoma and cancer degeneration when obesity is present. Associated liver steatosis is a significant risk factor for colorectal cancer.

Endoscopic placement of self-expanding stents in patients with symptomatic anastomotic leakage after colorectal resection for cancer: long-term results.

Anastomotic leak after colorectal resection for cancer is a challenging clinical problem. The postoperative quality of life in these situations is significantly impaired. We prospectively analyzed the effect of placing a self-expanding metal stent (SEMS) at the level of the leak, with or without proximal diverting ileostomy, in 22 patients with symptomatic anastomotic leakage after colorectal resection. The stents were placed successfully in all 22 patients. An proximal ileostomy was created in 15 patients under general anesthesia. The anastomotic leak healed, without evidence of residual stricture or major incontinence, in 19 patients (86 %). In 3 patients, the leak did not heal; in 2 patients with recurrent rectovaginal fistula, the size of the leak decreased significantly, allowing successful flap transposition; and only 1 patient required a permanent stoma. SEMS placement is a valid adjunct to the treatment of patients with symptomatic anastomotic leakage after colorectal resection.

Treatment of anastomotic stenosis and leakage after colorectal resection for cancer with self-expandable metal stents.

BACKGROUND: Self-expandable metallic stents can be used to treat patients with symptomatic anastomotic complications after colorectal resection. METHODS: Twenty patients with symptomatic anastomotic stricture after colorectal resection were treated with endoscopic placement of a self-expandable metal stent. Ten patients had "simple" anastomotic stricture. In the remaining 10 patients, a leak was associated with the stricture. RESULTS: The anastomotic leakage healed without evidence of residual stricture or major fecal incontinence in 8 of 10 patients. Overall, the anastomotic stricture was resolved in 14 of the 20 patients. CONCLUSIONS: Self-expandable metal stents represent a valid adjunctive to treat patients with symptomatic anastomotic complications after colorectal resection for cancer. They have a complementary role to balloon dilatation in case of simple anastomotic stricture, and they improve the rate of healing when the stricture is associated with a leak.

Bartholin's gland hyperplasia. Case report and a review of literature.

BACKGROUND: Tumors arising from glands of the female ano-genital area, such as minor and major vestibular glands, are very rare. Lesions affecting Bartholin's gland can be divided into two groups: benign and malignant lesions. In the first group we can include nodular hyperplasia, adenoma, adenomioma which can sometimes cause Bartholin's gland enlargement and difficult differential diagnosis. Surgery is considered the treatment of choice, frequently represented by marsupialization with rates of local recurrence. CASE REPORT: We describe a case of a 50-year-old woman with a several-years history of recurrent episodes of Bartholinitis, previously treated with marsupialization. Patient underwent complete excision of the left Bartholin's gland without operative complications. Pathological findings showed a Bartholin's gland hyperplasia. Post-operative course was regular, free from surgical complications. After one year, the patient is free from any local disease. RESULTS AND CONCLUSION: In women in postmenopausal age, in those cases in which marsupialization doesn't lead to an improvement in symptomatology and in those cases in which, at physical examination, Bartholin's gland enlargement appeared to be firm and irregular, because of the higher incidence of malignancy in these situations, total excision of the gland is recommended. Total excision of the Bartholin's Gland is a safe technique, given the low incidence of procedure- related morbilities. We do not consider biopsy of the gland a proper strategy for the high percentage of false negative results.

Endoscopic stenting for gastric outlet obstruction in patients with unresectable antro pyloric cancer. Systematic review of the literature and final results of a prospective study. The point of view of a surgical group.

BACKGROUND: The authors report the final results of a prospective single-center randomized study whose aim was to compare the endoscopic placement of self-expandable stents with open surgical gastroenterostomy to relieve gastric outlet obstruction (GOO) in patients with advanced antropyloric adenocarcinoma. A systematic review of the medical literature from December 1999 to December 2011 was carried out to determine the results of endoscopic stenting in patients with GOO from unresectable primary cancer of the antropyloric region. METHODS: In the prospective study, 18 patients with advanced adenocarcinoma of the antropyloric region and symptoms of GOO were enrolled. In 9 patients, self-expandable stents were placed, and in 9 patients, open surgical gastroenterostomy was performed. Patients were followed until death. Six hundred seventy-two patients with primary unresectable cancer of the antropyloric region and GOO syndrome who underwent endoscopic stenting were identified from the literature. RESULTS: In the prospective study of 18 patients, there was no case of postprocedural mortality. Efficient gastric emptying resumed more quickly in patients who received stents, although 3 months after the procedures, there was no difference between the 2 groups. Mean crude survival was 258 days in patients who received stents and 283 days in those who underwent surgical gastroenterostomy (P = NS). In patients who underwent stent placement, there were 2 cases of stent migration and 2 cases of food impaction, which were resolved with endoscopy at a mean follow-up of 70 days. In the 672 patients from the literature, operative mortality and morbidity were very low. In prospective studies, complications related to stents were more common than previously thought. CONCLUSIONS: Endoscopic placement of metallic stents offers an effective therapy in patients with advanced primary adenocarcinoma of the antropyloric region and poor general condition. In patients with longer life expectancies, the form of therapy should be chosen individually, considering that surgical gastroenterostomy has fewer complications in the medium term and that in patients with endoscopic stenting, very careful follow-up is required, with the possibility of new operative endoscopy in half of the patients.

A new technique for placement of a self-expanding metallic stent (SEMS) in patients with colon rectal obstruction: a prospective study of 43 patients.

BACKGROUND: Self-expanding metallic stent (SEMS) placement is a valid form of therapy for patients with obstructing colon rectal cancer. The procedure is not feasible for a minority of patients with a very low risk of bowel perforation. This report analyzes the results of a technical detail used for SEMS placement. METHODS: In 43 patients with colon rectal obstruction, the SEMS apparatus was introduced through a guidewire passed above the obstruction in the channel of a pediatric nasogastroscope (diameter, 4.9 mm). The pediatric nasogastroscope was passed into the obstruction and above, allowing the anatomy of the colorectal lesion and the passage of the guidewire to be visualized directly. RESULTS: The SEMS was inserted successfully in all cases without complications. In a previous series of 82 patients who had passage of the guidewire through the obstruction blindly, four technical failures occurred (nonsignificant difference). CONCLUSIONS: A pediatric nasogastroscope can be useful for passing the colon rectal obstruction and guiding the passage of the guidewire under direct vision.

Self-expandable metallic stents in patients with stage IV obstructing colorectal cancer.

BACKGROUND: The aim of the present study was to analyze the results of our experience with elective placement of self-expandable metallic stents (SEMS) in patients with stage IV obstructing colorectal cancer. A systematic review of the literature was also carried out to analyze the factors influencing the results of SEMS placement and to determine if there has been any improvement in the more recent period. MATERIALS AND METHODS: The results of a personal series of 100 patients were analyzed. There was no case of mortality or major morbidity. The systematic review included 27 articles published from April 2007 to December 2011. RESULTS: In our experience the technical success rate was 96% and the clinical success rate was 92%. During the follow-up period a repeat colonoscopy was needed in 31% of the patients for recurrent symptoms of obstruction due to fecal impaction (19%), tumor growth (8%), or stent dislodgment (4%). Review of the literature showed similar results, with a significant improvement in the reports of the last 6 years; procedures performed on an emergency basis had poorer results. CONCLUSIONS: Self-expandable metallic stent placement offers a valid alternative to surgery in patients with obstructing stage IV colorectal cancer, but careful follow-up is required.

Endoscopic treatment of ganglioneuroma of the colon associated with a lipoma: a case report.

INTRODUCTION: Ganglioneuromas are rare benign peripheral neuroblastic tumors characterized by hyperplasia of ganglion cells, nerve fibers, and supporting cells. They are not usually localized in the colon. CASE PRESENTATION: A 61-year-old Caucasian man was admitted to our department for colon cancer screening. A colonoscopy revealed a lipoma of 5cm in diameter, two micropolyps of less than 1cm, and one sessile polyp of 0.6cm in diameter. The polyps were removed with hot biopsy forceps. A histological examination revealed two hyperplastic polyps and one ganglioneuroma polyp. A follow-up colonoscopy showed no signs of recurrence after 16 months. CONCLUSIONS: Although a few cases of lipomas associated with ganglioneuromatous syndrome have been reported, the association of an intestinal lipoma with an isolated ganglioneuroma polyp has not been described. The implications of this association are unknown.

Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial.

BACKGROUND: Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction. METHODS: In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death. RESULTS: There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125-612 days) in patients who had stents and 280 days (range, 135-591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure. CONCLUSIONS: Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.

A study on metals content in patients with colorectal polyps.

Data on metals involvement in colorectal polyps are scarce and fragmentary. The aim of this study was to examine whether the level of metals could be associated with risk of colorectal polyp development. The concentration of 15 chemical elements (Al, Ba, Ca, Cd, Co, Cr, Cu, Fe, Hg Mg, Mn, Pb, Se, Sr, and Zn) in 17 colorectal biopsies of healthy individuals, in 15 polypotic and corresponding nonpolypotic biopsies taken from the same individual, was evaluated. Concentration in polyps of metals such as Al, Ca, Mg, Mn, Pb, Sr, and Zn was unchanged both in unpaired and paired samples; elements such as Ba, Cd, and Hg were significantly lower and Fe was significantly higher both in individual and paired tissues. Cobalt, Cr, and Cu were significantly different only between polyps and the adjacent normal tissue area; Se showed a significant accumulation comparing polyps versus healthy tissues. The difference found in some elements between polyps and a control tissue provides an indication about the role of essential and nonessential elements in the early stage (polyps) in the colon carcinogenic process and encourages further studies to confirm the involvement of such elements in neoplastic processes.

Determination of 30 elements in colorectal biopsies by sector field inductively coupled plasma mass spectrometry: method development and preliminary baseline levels.

An analytical procedure applicable to restricted sample sizes was developed and applied to the analysis of 30 chemical elements in colorectal biopsies of healthy patients. Acidic microwave digestion processed

Colorectal polyps: detection with low-dose multi-detector row helical CT colonography versus two sequential colonoscopies.

PURPOSE: To prospectively evaluate the diagnostic accuracy of low-radiation-dose computed tomographic (CT) colonography for detection of colorectal polyps by using two sequential colonoscopies, with the second colonoscopy as the reference standard. MATERIALS AND METHODS: The study was local ethics committee approved, and all patients gave written informed consent. Colonographic images were acquired by using a low-dose multi-detector row CT protocol (effective milliampere-second setting, 10 mAs). Three observers interpreted the CT colonographic data separately and independently by using a two-dimensional technique. Initial conventional colonoscopy was performed by an endoscopist unaware of the CT colonographic findings. Second colonoscopy performed within 2 weeks by a colonoscopist aware of both the CT colonographic and the initial colonoscopic findings served as the reference standard. The sensitivities of CT colonography and initial colonoscopy were calculated on a per-polyp and a per-patient basis. Specificities and positive and negative predictive values also were calculated on a per-patient basis. RESULTS: Eighty-eight patients underwent CT colonography and initial conventional colonoscopy on the same day. Per-polyp sensitivities were 62% and 83% for CT colonography and initial colonoscopy, respectively. Sensitivities for detection of polyps 6 mm in diameter or larger were 86% and 84% for CT colonography and initial colonoscopy, respectively. Initial colonoscopy failed to depict 16 polyps, six of which were correctly detected with CT colonography. For identification of patients with polyps 6 mm in diameter or larger, CT colonography and initial colonoscopy, respectively, had sensitivities of 84% and 90%, specificities of 82% and 100%, positive predictive values of 70% and 100%, and negative predictive values of 91% and 95%. CONCLUSION: Low-dose CT colonography compares favorably with colonoscopy for detection of colorectal polyps 6 mm in diameter or larger, with markedly decreased performance for detection of polyps 5 mm in diameter or smaller.

Computed tomographic colonography without cathartic preparation for the detection of colorectal polyps.

BACKGROUND AND AIMS: We prospectively compared the performance of low-dose multidetector computed tomographic colonography (CTC) without cathartic preparation with that of colonoscopy for the detection of colorectal polyps. METHODS: A total of 203 patients underwent low-dose CTC without cathartic preparation followed by colonoscopy. Before CTC, fecal tagging was achieved by adding diatrizoate meglumine and diatrizoate sodium to regular meals. No subtraction of tagged feces was performed. Colonoscopy was performed 3-7 days after CTC. Three readers interpreted the CTC examinations separately and independently using a primary 2-dimensional approach using multiplanar reconstructions and 3-dimensional images for further characterization. Colonoscopy with segmental unblinding was used as reference standard. The sensitivity of CTC was calculated both on a per-polyp and a per-patient basis. For the latter, specificity, positive predictive values, and negative predictive values were also calculated. RESULTS: CTC had an average sensitivity of 95.5% (95% confidence interval [CI], 92.1%-99%) for the identification of colorectal polyps > or =8 mm. With regard to per-patient analysis, CTC yielded an average sensitivity of 89.9% (95% CI, 86%-93.7%), an average specificity of 92.2% (95% CI, 89.5%-94.9%), an average positive predictive value of 88% (95% CI, 83.3%-91.5%), and an average negative predictive value of 93.5% (95% CI, 90.9%-96%). Interobserver agreement was high on a per-polyp basis (kappa statistic range, .61-.74) and high to excellent on a per-patient basis (kappa statistic range, .79-.91). CONCLUSIONS: Low-dose multidetector CTC without cathartic preparation compares favorably with colonoscopy for the detection of colorectal polyps.

Malignant intestinal obstruction: useful technical advice in self-expanding metallic stent placement.

BACKGROUND: The use of endoluminal self-expanding metallic stents is an effective alternative to surgery in neoplastic gastrointestinal tract obstructions. It is often difficult to mark the proximal segment of the stricture under fluoroscopic guidance (due to patient movements or change of markers' position). PATIENTS AND METHODS: We placed Ultraflex precision colonic stent (Microvasive, Boston Scientific) in ten patients with neoplastic stricture of the rectosigmoid colon. Before placement of the delivery catheter, a radiopaque proximal marker was identified on the delivery catheter under fluoroscopic guidance. The external side of the delivery catheter was coloured (in correspondence with the radiopaque marker) with non toxic colour. After the introduction of the delivery catheter, we placed the proximal coloured marker just above the distal tumour margin under endoscopic guidance. RESULTS: The procedure was successful in relieving the obstruction in all patients, without mortality or complications. In all patients the coloured marker was identified and the stent correctly placed. CONCLUSION: The location of a coloured marker in the external side of the delivery catheter permits an accurate and correct placement of the stent, without unnecessary exposure to X-rays.