Acute afferent loop obstruction treated by endoscopic decompression. Case report and review of literature.

Afferent loop syndrome (ALS) is a rare complication of Billroth-II gastrojejunostomy. Most cases of ALS are caused by obstruction from adhesions, kinking at the anastomosis, internal hernia, stomal stenosis, malignancy, or inflammation surrounding the anastomosis. A 61-years old man, who had undergone gastric resection 30 years before, was admitted at emergency room with severe abdominal pain in acute onset, nausea and vomiting. Ultrasonography and multi-detector computed tomography suggested acute ALS, due probably to adhesions or internal hernia. The patient was conducted to digestive endoscopy unit and successfully treated with endoscopic decompression of dilated afferent loop. Open surgery is actually considered the gold-standard in treatment of ALS. However, some surgeons report a few cases treated by laparoscopic surgery, interventional radiology techniques, endoscopic decompression. Authors suggest endoscopic decompression of acute ALS due to adhesions or internal hernia as the first treatment, especially in high-surgical-risk patients.

Screening for colorectal cancer in Italy: 2005 survey.

We present the main results from the second survey of the Italian screening programmes for colorectal cancer carried out by the National Centre for Screening Monitoring on behalf of the Ministry of Health. During 2005, 52 programmes, adopting faecal occult blood testing (FOBT), sigmoidoscopy (FS), or a combination of both, were active in Italy. Overall, 827,473 subjects were invited to FOBT and 376,240 were screened; the adjusted attendance rate (47.1%) equals the best performances reported in the literature. Positivity rate of FOBT programmes was 5.8% at first and 4.1% at repeat screening: it increased with age and was higher among males than females in all age groups. The average attendance rate to colonoscopy (TC) was 82% (range: 56%-100%). Completion rate of TC was 91%, with higher rates among males. At first screening, the detection rate (DR) per 1000 screened subjects was 3.7 and 16.8 for invasive cancer and advanced adenomas (AA) (adenomas with a diameter > or =1 cm, with villous/tubulo-villous type or with high-grade dysplasia) respectively; the corresponding figures at repeat screening were 1.1 for cancer and 4.9 for AA. The DR of cancer and adenomas increased with age and it was higher among males, 55% of screen-detected cancers were at TNM stage I. The positive predictive value (PPV) was 7.4% for cancer and 32.9% for AA at first screening, and 4.5% for cancer and 20.5% for AA at repeat screening. Given this high PPV of positive FOBT, to obtain a high attendance at TC is crucial. The six FS programmes invited almost half of their target population (about 40,000 subjects) and 5,821 subjects were screened, with an attendance rate of 29.1%. Overall 89.0% of FS were classified as complete. TC referral rates ranged between 7.7 and 13.8%, due to different referral criteria. Among subjects referred to colonoscopy the prevalence of proximal AA and cancer ranged from 5.4 to 11.1%. The overall DR (subjects with at least one advanced lesion) ranged from 3.5 to 7.0%. In conclusion, during 2005 the organised programmes for colorectal cancer screening in Italy increased considerably, covering about one third of the eligible population at a national level. Many programmes were activated in the second part of the year, thus their results have to be evaluated with caution. However, the reported experiences showed good results in terms of attendance and DR, although some critical aspects need to be carefully addressed when planning and implementing screening activity.

Gabexate or somatostatin administration before ERCP in patients at high risk for post-ERCP pancreatitis: a multicenter, placebo-controlled, randomized clinical trial.

BACKGROUND: ERCP is frequently complicated by pancreatitis. The aims of this study were to assess the efficacy of somatostatin and gabexate for prevention of post-ERCP pancreatitis in high-risk patients and to determine predisposing factors for post-ERCP pancreatitis. A meta-analysis was conducted of all published studies on the use of somatostatin or gabexate for prevention of post-ERCP pancreatitis. METHODS: A double blind, multicenter, placebo-controlled trial was conducted in patients at high risk for post-ERCP pancreatitis. Patients were randomized to receive an intravenous infusion of somatostatin (750 mg), gabexate (500 mg), or placebo that was started 30 minutes before endoscopy and continued for 2 hours afterward. Patients were evaluated clinically and serum amylase levels determined at 4 and 24 hours after endoscopy. RESULTS: No significant difference in the occurrence of pancreatitis, hyperamylasemia, or abdominal pain was observed among placebo-, gabexate-, and somatostatin-treated patients. A sphincterotomy longer than 2 cm (p = 0.0001), more than 3 pancreatic injections (p = 0.0001), and unsuccessful cannulation (p = 0.008) were predictive of post-ERCP pancreatitis. Hyperamylasemia was predicted by more than 3 pancreatic injections (p = 0.0001) and sphincterotomy (p = 0.02). The meta-analysis of trials of short-term infusion of gabexate or somatostatin did not show efficacy for either drug. CONCLUSIONS: Short-term administration of gabexate or somatostatin in patients at high risk for pancreatitis is ineffective for prevention of ERCP-induced pancreatitis. Pancreatic injury is related to maneuvers used to obtain biliary access rather than to any patient characteristic or endoscopist experience.