Randomized comparison of power Doppler ultrasonography-guided core-needle biopsy with open surgical biopsy for the characterization of lymphadenopathies in patients with suspected lymphoma.

The sensitivity of lymph node core-needle biopsy under imaging guidance requires validation. We employed power Doppler ultrasonography (PDUS) to select the lymph node most suspected of malignancy and to histologically characterize it through the use of large cutting needle. Institutional review board approval and informed consent were obtained for this randomized clinical trial. In a single center between 1 January 2009 and 31 December 2015, patients with lymph node enlargement suspected for lymphoma were randomly assigned (1:1) to biopsy with either standard surgery or PDUS-guided 16-gauge modified Menghini needle. The primary endpoint was the superiority of sensitivity for the diagnosis of malignancy for core-needle cutting biopsy (CNCB). Secondary endpoints were times to biopsy, complications, and costs. A total of 376 patients were randomized into the two arms and received allocated biopsy. However, four patients undergoing CNCB were excluded for inadequate samples; thus, 372 patients were analyzed. Sensitivity for the detection of malignancy was significantly better for PDUS-guided CNCB [98.8%; 95% confidence interval (CI), 95.9-99.9] than standard biopsy (88.7%; 95% CI, 82.9-93; P < 0.001). For all secondary endpoints, the comparison was significantly disadvantageous for conventional approach. In particular, estimated cost per biopsy performed with standard surgery was 24-fold higher compared with that performed with CNCB. The presence of satellite enlarged reactive and/or necrotic lymph nodes may impair the success of an open surgical biopsy (OSB). PDUS and CNCB with adequate gauge are diagnostic tools that enable effective, safe, fast, and low-cost routine biopsy for patients with suspected lymphoma, avoiding psychological and physical pain of an unnecessary surgical intervention.

Proinflammatory stimuli activates human-derived enteroglial cells and induces autocrine nitric oxide production.

BACKGROUND: Enteric glial cells (EGCs) have been recently indicated as key regulators of intestinal inflammation in animals. Whether or not this is true and how these cells participate to inflammatory responses in humans is unknown. METHODS: We isolated primary EGCs from human small bowel and then, we purified and characterized those using specific glial markers, such as S100B and glial fibrillary acidic protein (GFAP). To mimic an inflammatory scenario, we exposed EGCs to exogenous stimuli, such as lipopolysaccharide and interferon-gamma (LPS and IFN-γ), alone or in combination, to evaluate glial activation [measuring GFAP, S100B level together with c-fos, major histocompatibility complex (MHC) class II, inducible nitric oxide (iNOS) proteins expression and nitric oxide (NO) production] and proliferation, respectively. KEY RESULTS: We showed that, when challenged with a combination of LPS and IFN-γ, EGCs are significantly activated, as indicated by their positivity to c-fos and MHC class II. Similarly, pro-inflammatory stimuli significantly increase the cell proliferation rate, the expression of both S100B and GFAP, and the NO production consequent to the induction of EGCs-derived iNOS protein, with the last being dependent on S100B-RAGE (receptor for advanced glycation endproducts) interaction. CONCLUSIONS & INFERENCES: Our data provide the first evidence that human EGCs directly respond to pro-inflammatory stimuli by changing their expression profile and by proliferating. The finding that stimulated EGCs are able to produce NO points to a role of this cell population in the scenario of intestinal inflammation.

A NOTES approach for thoracic surgery: transgastric thoracoscopy via a diaphragmatic incision in a survival porcine model.

AIM: Recently the NOTES approach has been extended to mediastinum by a transesophageal access and to the thorax by a transvescical endoscopic approach. The aim of this study was to assess the feasibility and the safety of transgastric endoscopic approach to the thoracic cavity, with lung biopsy, in a survival porcine model. METHODS: The study was performed on four 20-30 kg female pigs (Sus scrofus domesticus). Following gastric wall incision, the muscular pars of the left diaphragmatic dome was incised along with the parietal pleura and the endoscope advanced into the thoracic cavity. In all animals, a thoracoscopy was performed as well as peripheral lung biopsy. At the end of the operation the endoscope was withdrawn from the thoracic cavity after pleural sac decompression and the diaphragmatic incision closed by endoscopic clips under maximal expansion of lungs. The gastric incision was finally closed by endoscopic clips. Chest-tube placement was not utilized. Animals were sacrificed by day 15 postoperatively. RESULTS: The gastroscope was easily introduced into the thoracic cavity that allowed to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. No adverse event occurred during the survival period. The postmortem examination 15 days after surgery revealed a good closure of the diaphragmatic incision. At necropsy, the lung biopsies were completely healed. There were no signs of infection in both thoracic and peritoneal cavities. The length of follow-up and number of animals studied might have not been sufficient. CONCLUSION: This study demonstrates the feasibility of transgastric thoracoscopy in porcine model. Long-term follow-up of much larger series will be necessary for provision of more reliable answers if this approach should be adopted in the future and eventually translated for humans with advantages for patients.

Natural orifices transluminal endoscopic surgery (NOTES): an overview of technical challenges and complications of transgastric procedures in anesthetized pigs.

AIM: Natural orifice transluminal endoscopic surgery (NOTES) is a new reality that is progressively gaining popularity in the scientific community. The aim of this study was to report the authors' experience with various peroral transgastric procedures performed on the porcine model. The technical difficulties and challenges that arose were also analyzed. METHODS: Ten anesthetized pigs, divided into an acute (3) and a survival group (7) underwent the following procedures using a double channel endoscope: peritoneoscopy (10), cholecystectomy (6),splenectomy (3), and gastrojejunostomy (3). RESULTS: All the procedures were completed successfully. There was one complication related to the gastric wall incision. In the survival experiment group all pigs (4) submitted to biliare procedures made an uncomplicated recovery after a follow-up period of 2 weeks. Gastrojejunostomies (3) were instead graved by one technical failure (anastomosis disruption at post-mortem examination) and one case of mortality (premature euthanasia for evidences of sepsis). Complete gastric cleansing was impossible to achieve and overinflation was a common problem. The creation of gastro-enteric anastomoses was technically difficult with the current available devices. CONCLUSION: Transgastric endoscopic surgery is technically feasible in a porcine model. A new instrumentation is needed and could strongly help to overcome the technical difficulties highlighted. More extensive animal studies are mandatory in order to evaluate the benefits and the limitations of this new technique.

The biological characterization of neuroendocrine tumors: the role of neuroendocrine markers.

Neuroendocrine tumors (NET) may originate in different organs, from cells embryologically different but expressing common phenotypic characteristics, such as: the immuno-reactivity for markers of neuroendocrine differentiation (defined as "pan-neuroendocrine"), the capacity to secrete specific or aspecific peptide and hormones and the expression of some receptors, that are at the basis of the current diagnostic and therapeutical approach, peculiar to these tumors. NET have been conventionally distinguished in functioning, when associated with a recognized clinical endocrine syndrome, and non-functioning. However, this terminology may be misleading, since the great majority of NET may secrete neuroendocrine peptides, which can be employed as clinical markers for both diagnosis and follow-up. On the other hand, tissue immuno-reactivity for specific hormones does not always reflect secretory activity of the tumor cells. Finally, receptors and genetic markers are acquiring a relevant role in the characterization of NET, both improving knowledge of biology and physiopathology of NET, as well as in developing specific strategies to establish an early diagnosis and targeted therapies, to adopt prophylactic strategies in familial forms, and to identify more efficacious targets for therapy in the future.

Acute gastrointestinal bleeding following aortic valve replacement in a patient with Heyde's sindrome. Case report.

A 58-year old man was admitted to the hospital because of melena. He had a 1-year history of mechanical aortic valve replacement and coronary stent placement because of myocardial infarction and he was taking warfarin and clopidogrel. Esophagogastroduodenoscopy and colonoscopy were negative for bleeding. Capsule endoscopy showed bleeding diffuse angiodysplasia of the small bowel. The patient was treated with octreotide 20 mg, at monthly interval. After 25 months there had been no recurrence of gastrointestinal bleeding. The case suggests that mechanical valve replacement may not prevent gastrointestinal bleeding in Heyde syndrome and that octreotide treatment should be considered in these cases.

Epidemiology of non-gastroenteropancreatic (neuro)endocrine tumours.

The widespread availability and reliability of immunohistochemical techniques in the last three decades have allowed researchers to identify cells with common neuroendocrine markers in virtually every organ. As a whole, these neuroendocrine cells form the so-called diffuse neuroendocrine system. Tumours arising from the cells of the diffuse neuroendocrine system are defined as (neuro)endocrine tumours (NETs). NETs have been increasingly described in recent years. However, despite the increase in the number of published papers focused on NET, we still lack adequate epidemiological data, particularly for non-gastroenteropancreatic (GEP) NETs. Furthermore, the real incidence of neuroendocrine differentiation for most sites is not completely known and is probably underestimated. As a consequence, data on the clinical features of many NET subgroups are not well known or confusing. For all of these reasons, we have attempted to evaluate the epidemiology of non-GEP NETs, reviewing the limited data available in the literature.

Mean and long-term results of the surgical treatment of early gastric cancer.

AIM: Interest in the diagnosis and treatment of early gastric cancer (EGC) has been steadily increasing due to the high 5-year survival rate which can reach 85-100% after curative resection. The aim of this retrospective study was to analyze the clinical and histologic characteristics as well as the results of 45 patients undergoing surgical resection for EGC. METHODS: Between 1998 and 2004, 45 patients, 14 females and 31 males with a mean age of 60.2+/-15 years (range: 31-85) were recruited. Subtotal gastrectomy was performed in 28 (62.2%) patients and total gastrectomy in 17 (37.3%). D1 and D2 resections were performed in 36 and 9 patients, respectively. The carcinoma was limited to the mucosa in 26 (57.8%) patients and extended into the submucosa in 19 (42.2%). Lymph node invasion occurred in 4 (8.8%) patients. Mean follow-up was 36 months (range: 3-63). Survival was calculated using the Kaplan-Meier method. Multivariate analysis of clinic and histologic factors was performed to identify predictive factors for survival. RESULTS: The 5-year actuarial survival rate was 85% and there was no postoperative mortality. Statistical analysis did not demonstrate any significant statistical relationship between survival and parietal penetration (P = 0.67) or superficial extension (P = 0.38) of the tumor. Survival was clearly influenced (P < 0.001) by lymph node involvement. CONCLUSIONS: Prognosis of EGC is usually excellent but can be influenced by the presence of lymph node metastases.

Endovascular procedures in critical leg ischemia of elderly patients.

PURPOSE: Purpose of this study was to evaluate angiographic and clinical results of popliteal, infrapopliteal, and multi-level disease percutaneous transluminal angioplasty (PTA) in over-80 years old patients with chronical clitical leg ischemia. In fact such patients with extensive peripheral vascular disease and critical limb ischemia (CLI) are generally poor surgical candidates. METHODS: Between 1998 and 2003, 37 elderly patients aged 80-89 years old (mean age 83.3) with critical leg ischemia were treated with PTA. All patients were at high surgical risk. 31/37 (81.5%) patients had chronic non-healing wounds, and 14/37 (37%) had multi-level disease of superficial femoral, popliteal and crural arteries. One hundred and two lesions were treated by angioplasty. Immediate angiographic and 1 year clinical results were retrospectively analyzed. RESULTS: The overall procedural success rate was 32/37 (84.2%). There were three major complications (7.9%), but no deaths, and three technical failures, all were of infrapopliteal lesions. After 1 year, 27 patients could be followed, five patients died during the first year of unrelated causes. Twenty-three patients (85.2%), were clinically re-occluded within 1 year, but complete and partial wound healing was achieved in 80% (16/20) and rest pain improvement in 57% (4/7), so that overall limb salvage was 74% (20/27). CONCLUSIONS: Elderly patients with multi-level CCLI have a short patency term following angioplasty of 14.8% after 1 year. Nevertheless, this temporary vascular patency enables wound healing or improvement in 74% of these patients, thus such endovascular interventions are recommended in this age group.

Carotid endarterectomy under local anesthesia in elderly: is it worthwhile?

Carotid endarterectomy (CEA) has a positive effect on stroke free survival in patients with either symptomatic or asymptomatic severe carotid bifurcation stenosis. However, most trials have excluded elder patients. In addition, concerns have arisen regarding the benefits of CEA in the elderly population, especially in women. In this study, we performed an outcome analysis in patients undergoing CEA comparing those eighty and older to their younger counterparts. A total of 262 carotid operations were performed under local anaesthesia between 1998 and 2004; 76 (34%) were carotid reconstructions in 70 patients over 75 yr of age. Twenty patients (26%) presented with asymptomatic critical stenosis. Transient ischemic symptoms were the reason for presentation in 35 patients (46%). Progressive stroke was documented in two patients (3%) and a stroke with persisting neurological deficit was demonstrated in 19 cases (25%). Coronary artery disease was present in 47 patients (38%) and arterial hypertension in 55 (72%). Fifty-nine patients (84%) were classified as ASA group 3. Seventy-one thromboendarterectomies of the carotid bifurcation with direct closure were performed. Five patients had other types of reconstruction. Postoperative complications occurred in three patients. One had a transient neurological deficit and another a lethal stroke; the third patient died from myocardial infarction. The in-hospital mortality was 2.9%, which was not significantly higher than the results of the reconstructions in younger patients (1.5%). Surgery for carotid artery occlusive disease under local anaesthesia can be safely performed in selected patients of more than 75 yr of age.

[Ultrasound-guided endoscopic drainage, without radiological examination, in patients with neoplastic biliary obstruction. Preliminary results]. / Sulla possibilità di drenaggio endoscopico, sotto guida ecografica, senza controllo radiologico, in pazienti con stenosi neoplastiche della via biliare principale. Risultati preliminari.

AIM: Endoscopic stent insertion has become the preferred method for palliation of malignant biliary obstruction. Currently, endoscopic stent placement involves the use of contrast media and radiological equipment to achieve direct opacification of the biliary duct systems, and to determine the location and the extension of biliary obstruction. This report proposes a new combination of ultrasonography and biliary endoscopy, with endoscopic stent placement entirely performed under US-guidance. METHODS: US-guided stent placement was carried out in 8 patients. A guide-wire and a guiding-catheter were endoscopically introduced and identified, by US, the common bile duct across the stricture. Hydromer-coated polyurethane angled stents (10F) were finally inserted over the guide-wire/guiding-catheter by a pusher tube system. RESULTS: Successful stent insertion was achieved in all patients. There were no complications. Successful drainage, with substantial reduction in bilirubin level, was achieved in all patients (14.2+/-9.5 vs 4.2+/-2.9 mg/dl at 1 week). CONCLUSION: Endoscopic stent placement performed under US-guidance, is safe and effective. Further studies in a larger series, including more proximal strictures are suggested.

[Endoscopic palliative treatment of the common bile duct at the hepatic hilum. Results in 583 patients treated in a single center over a 10-year period]. / Trattamento palliativo per via endoscopica delle stenosi della via biliare principale all'ilo epatico. Risultati in 583 pazienti trattati in un singolo Centro in 10 anni.

BACKGROUND: The outcomes of endoscopic biliary drainage for malignant stenoses at the hepatic hilum were retrospectively evaluated. METHODS: From January 1990 to June 2001, 583 patients, 368 males, average age 69+/-18.5 years, were recruited. Endoscopic procedure consisted of insertion of 1 ore multiple stents, plastic or metallic, across the stricture, under mild sedation. RESULTS: Successful stent insertion was achieved in 518/583 (88.8%) patients and successful drainage in 474 (81.3%) patients. Early complications were observed in 101 (17.3%) patients with related-mortality of 17 (2.9%) patients. Late complications occurred in 39.9% of patients. Survival was of 189 days, on average. CONCLUSIONS: Endoscopic palliation should be the initial management of choice for malignant biliary stenoses at the hepatic hilum.

[Long-term results of endoscopic treatment of biliary stenosis from laparoscopic cholecystectomy]. / Risultati a lungo termine del trattamento per via endoscopica delle stenosi della via biliare principale da colecistectomia laparoscopica.

BACKGROUND: The outcome of endoscopic biliary stent insertion for postoperative bile duct stenosis was retrospectively evaluated. METHODS: Fifty-seven patients with biliary stenosis from laparoscopic cholecystectomy were included from February 1992 to January 2000. One to three stents were inserted for an average of 12.4 months, with stent exchange every three months to avoid cholangitis caused by obstruction. RESULTS: Successful stent insertion was achieved in 43/57 (75.4%) patients. Stent insertion failed in 10 patients with complete and four patients with incomplete biliary obstruction. Early complications occurred in four patients. Late complications occurred in 5/43 patients. Five patients experienced recurrence of stenosis. CONCLUSIONS: Endoscopic treatment should be the initial management of choice for postoperative bile duct stetiosis.

Biliary leaks after laparoscopic cholecystectomy. Results of the endoscopic treatment.

BACKGROUND: Significant postoperative bile leaks occur in approximately 0.8 to 1.1% of patients. The goal of endoscopic therapy is to eliminate the transpapillary pressure gradient, thereby permitting preferential transpapillary bile flow rather than extravasation at the site of leak. METHODS. Sixty-four patients were retrospectively evaluated. Endoscopic treatment comprised endoscopic sphincterotomy followed by insertion of a naso-biliary drainage or a stent. Retained stones were extracted by standard procedures. RESULTS: The cystic duct remnant was the site of bile extravasation in 50 cases, ducts of Luschka were the source in 4 cases, common bile duct in 6 cases and common hepatic duct in 4 cases. Retained bile duct stones were detected in 21 cases and papillary stenosis in 4 cases. Endoscopic therapy involved sphincterotomy in 25 cases with stones extraction in 21 cases followed by nasobiliary drain insertion, and placement of stent in the remainder. Bile leaks resolved in 96.9% of patients, on average 3 days in cases of associated stones or papillary stenosis, and 6.5 days in the remainder. Two cases of mild pancreatitis were evidenced from endoscopic treatment. CONCLUSIONS: Endoscopic management is the treatment of choice for postcholecystectomy bile leaks.

Self-expanding metal stents for endoscopic treatment of esophageal achalasia unresponsive to conventional treatments. Long-term results in eight patients.

BACKGROUND AND STUDY AIMS: The successful use of self-expanding metal stents has been demonstrated in the management of malignant esophagocardial strictures. This report assesses the role stents may play in the treatment of esophageal achalasia in selected patients. PATIENTS AND METHODS: Between September 1996 and December 1997, eight patients (two men, six women; average age 67.6 years) underwent insertion of a self-expanding metal stent for management of achalasia. Previous myotomy and/or balloon dilation or injection of botulinum toxin had failed in all patients. Four nitinol coil stents and five covered Ultraflex stents, 10 cm long, were inserted, being passed through the gastroesophageal junction under mild sedation. RESULTS: Stent placement was successful and uncomplicated in all patients. Early complications were seen in five patients: chest pain (1), gastroesophageal reflux (1), proximal migration (1), and distal migration (2). One patient underwent surgery for stent impaction in the colon. During the follow-up period of 35.5 months, on average (range 29 - 44 months), four patients experienced complications: chest pain (2), reflux esophagitis (1) and stent migration (1). CONCLUSION: General use of self-expanding metal stents for esophageal achalasia cannot be recommended.

[Personal experience with the endoscopic treatment of pancreatic pseudocysts. Long-term results and analysis of prognostic factors]. / Esperienza personale nel trattamento per via endoscopica delle pseudocisti pancreatiche. Risultati a lungo termine ed analisi dei fattori prognostici.

BACKGROUND: The aim of this study was to assess the safety and utility of endoscopic treatment of pancreatic pseudocysts. Prognostic factors for the outcome of endoscopic drainage were assessed in a prospective analysis. METHODS: Forty-nine consecutive symptomatic patients were included in the study. Transmural drainage was used in 30 patients and transpapillary drainage in 19 patients. RESULTS: Successful drainage was achieved in 27/30 (90%) of patients after transmural drainage and in 16/19 (84.2%) patients after transpapillary drainage. Twelve (24.5%) patients had complications; 2 patients had bleeding, 2 had mild pancreatitis, 8 had cyst infection, in relation to the presence of necrosis (5 patients) or stent clogging (3 patients). Nine patients (20.9%) had recurrence of pseudocyst. Endoscopic drainage was a definitive treatment in 37 out of 49 (75.5%) patients (median follow-up: 25.9 months). Presence of necrosis was the only significant prognostic factor for infectious complication. CONCLUSIONS: Endoscopic drainage provides a successful and safe minimally invasive approach to the management of pancreatic pseudocysts.

[Rare complications of biliary sepsis]. / Complicanze rare delle sepsi biliari.

The surgical approach to the acute biliary pathologies also today is often controversial. The choice of the right time to operate an acute patient is based either on personal clinical experiences, either under the statement that waiting for the resolution of the acute process could be preferable in the aim of reduce the surgical risk. This is the almost general tendency. Recently, some interesting articles issued by Swedish and German schools conducted as controlled trials on a great base of cases, try to emphasize the advantages of an early surgical therapy, particularly in the elderly patients. In these ones, in fact, the concomitance of cardiovascular, metabolic and immunodepressive pathologies makes more serious the complications too. In this article, the Authors refer on three clinical cases, all of which were quite different, and in which it was possible to identify a former septic hepato-biliary pathology. All the patients, upon hospital admission showed an acute pattern. In two cases it was an hepatic abscess, accompanied in one case by a "satellite" pulmonary abscess on the right lung. These two were treated conservatively, although by a TC-guided drainage of the liver abscesses. The third case, a localized choleperitoneum (biloma saccatus), underwent an operation. The accurate investigation on the clinical records of Authors' Department since 1980 to 1995 and in particular on the three referred cases seems to confirm that the importance of some complications after acute biliary pathology and their great morbidity must stimulate the surgeons to investigate always on the real causes of all clinical patterns, even if uncommon.