[The role of endoscopy in gastroenteropancreatic neuroendocrine tumors]. / Il ruolo dell'endoscopia nei tumori neuroendocrini gastroenteropancreatici.

Versione italiana Riassunto: Il ruolo dell'endoscopia nei tumori neuroendocrini gastroenteropancreatici. L. Magno, L. Sivero, V. Napolitano, S. Ruggiero, G. Fontanarosa, S. Massa I tumori neuroendocrini (NET) gastro-entero-pancreatici (GEP) sono neoplasie rare che originano dalle cellule neuroendocrine del tubo digerente e del pancreas. L'endoscopia digestiva e l'ecoendoscopia rivestono un ruolo importante nella diagnosi, stadiazione e sorveglianza dei pazienti con NET. Inoltre, in casi selezionati, le tecniche endoscopiche operative consentono il trattamento di queste neoplasie in fase precoce. English version Summary: The role of endoscopy in gastroenteropancreatic neuroendocrine tumors. L. Magno, L. Sivero, V. Napolitano, S. Ruggiero, G. Fontanarosa, S. Massa Gastroenteropancreatic (GEP) neuroendocrine tumors (NET) are rare neoplasia arisen from neuroendocrine cells present in the gut mucosa and pancreas. Digestive endoscopy and endoscopic ultrasonography play a relevant role in NET diagnosis, stadiation and surveillance. Moreover, in selected patients, surgical endoscopy allows the tratment of these cancers at an early stage.

A case of infectious esophagitis caused by human papilloma virus.

Esophageal infections may be caused by diverse pathogens that alter the mucosal lining and produce mild symptoms or sometimes critical clinical diseases with a high risk of mortality, particularly among the immunocompromised. The most common causes of infectious esophagitis are: herpes virus, candida, cytomegalovirus (CMV), and human immunodeficiency virus (HIV); human papilloma virus (HPV) infections are rare in Western countries. Endoscopic features of infectious esophagitis are specific for different agents; nonetheless, differential diagnosis is difficult and requires biopsy, cultures and brushing. We present the clinical case of a young woman admitted to the Department of General Surgery of A.O.U. Federico II, Naples, for a large, deep ulcerative lesion of the esophagus caused by HPV infection.

[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.

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.

[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.

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.

[Comparison of Nd-Yag laser and strip biopsy in the treatment of extensive adenomas of the rectum]. / Confronto tra Nd-YAG laser e strip biopsy nel trattamento degli adenomi estesi del retto.

This prospective study was carried out in order to compare endoscopic laser therapy and strip biopsy for treatment of large sessile rectal adenomas. Between January 1990 and December 1991, 94 consecutive patients, referred to our Endoscopy Service because of extensive rectal adenoma have been allocated to laser therapy or strip biopsy. The effectiveness of the two techniques was statistically the same from many points of view: complete ablation (76.7% vs 71.4%), recurrence (35.4% vs 30.6%) need for surgical intervention (12% vs 16.6%) and complication rates. However, from our experience, the treatment period was significantly shorter for patients affected by an intermediate sized adenoma and treated with strip biopsy. In both groups, instead, complete, permanent ablation was difficult to obtain in the cases of extensive lesions and in particular if they were localized lower than 5 cm from the anus.

[Personal experience in the treatment of esophago-cardial stenosis with the Nd-YAG laser]. / Esperienza personale nel trattamento con Nd-YAG laser delle stenosi esofago-cardiali.

The authors analyze the results of treatment, by Nd-YAG laser. of benign and malignant esophageal and cardial stenoses. Particularly the personal technique, immediate and late complications and association with complementary techniques such as dilatation or intratumoral injection of polidocanol are evaluated.

[Endoscopic endoprosthesis in the palliative treatment of carcinoma of the pancreas]. / Le endoprotesi endoscopiche nel trattamento palliativo del carcinoma del pancreas.

Perendoscopic treatment of cancer of the pancreas may be carried out through bilionasal drainage or bilioduodenal drainage. These techniques are indicated for preventing choledochic stenosis due to cancer of the head of the pancreas and should be considered as palliative techniques in inoperable patients. The present paper particularly examines the role of biliary endoprosthesis, with special attention to the results obtainable in terms of improvement to the quality of life in patients with inoperable gallbladder-obstructing cancers.

[The results of bile culture after selective sampling of the main biliary tract via endoscopic catheterization. The relation of the microbes isolated, the anatomicopathologic picture and the possibility of septic complications following endoscopic cholangiopancreatography (ERCP)]. / Risultati della bilicoltura dopo prelievo selettivo dalla via biliare principale (V.B.P.) per mezzo di cateterismo perendoscopico. Rapporti fra i germi isolati, quadro anatomopatologico e possibilità di complicanze settiche dopo colangiopancreatografia endoscopica (E.R.C.P.).

Selective sampling from the main bile way using endoscopic catheterization was used in the attempt to establish parameters capable of identifying patients at risk of septic complications following endoscopic cholangiopancreatography. The results obtained evidenced a significant relationship between neoplastic type obstructions of the main bile way, age of patient and positive bile culture with increased risk of septic complications. The advisability of using local and/or systemic antibiotic prophylaxis in elderly patients with suspected neoplastic obstruction of the bile way and thus candidates for endoscopic cholangiopancreatography is considered.

[The current state of endoscopic polypectomy of the large intestine]. / Lo stato attuale della polipectomia perendoscopica del grosso intestino.

The current state of endoscopic polypectomy of the large intestine is analysed. The indications for this treatment and the main complications arising (haemorrhages, perforations, colonic rupture) are evaluated with details of possible treatment and/or prevention. The connections with histology and surgery are also discussed. Finally, the treatment and follow-up of cancerised rectocolonic polyps are discussed in detail.