Alessandro Gigliozzi

Predictors of favourable outcome in non-variceal upper gastrointestinal bleeding: Implications for early discharge?

BACKGROUNDnThere is a lack of validated predictors on which to decide the timing of discharge in patients already hospitalized for upper nonvariceal bleeding.nnnAIMSnIdentify factors that appear to protect nonvariceal bleeders from the development of negative outcome (rebleeding, surgery, death).nnnMETHODSnSecondary analysis of two prospective multicenter studies. Multivariate analyses for each investigated outcome were performed; a single model was developed including all factors that were statistically significant in each sub-model. A final score was developed to predict favourable outcomes. Prognostic accuracy was tested with ROC curve analysis.nnnRESULTSnOut of 2398 patients, 211 (8.8%) developed one or more adverse outcomes: 87 (3.63%) had rebleeding, 46 (1.92%) needed surgery and 107 (4.46%) died. Predictors of favourable prognosis were: ASA score 1 or 2, absence of neoplasia, outpatient bleeding, use of low-dose aspirin, no need for transfusions, clean-based ulcer, age <70 years, no haemodynamic instability successful endoscopic diagnosis/therapy, no Dieulafoys lesion at endoscopy, no hematemesis on presentation and no need for endoscopic treatment. Overall prognostic accuracy of the model was 83%. The final score accurately identified 20-30% of patients that eventually do not develop any negative outcome.nnnCONCLUSIONSnThe good luck score may be a useful tool in deciding when to discharge a patient already hospitalized for acute non-variceal bleeding.

A survey on mortality from non-variceal upper gastrointestinal bleeding: Is the emergency referral system adequate?

BACKGROUNDnNon-variceal upper gastrointestinal bleeding (NVUGIB) is an important cause of mortality and morbidity worldwide. Little information is available on the clinical management of non-variceal upper gastrointestinal bleeding in Italy in relation to the current organization of the Italian Emergency Health Services into Level-I and Level-II Emergency Departments (ED), the latter being more complex structures with greater resources.nnnMETHODSnA retrospective survey on clinical, endoscopic, and survival data was conducted by the regional sections of the 3 main Italian gastroenterological societies, AIGO, SIED and SIGE, recording all consecutive episodes of non-variceal upper gastrointestinal bleeding referred to 7 centres (4 of which were Level-II Emergency Departments) in Rome, Italy, during a one-year period. A total of 624 consecutive patients (64% males, mean age 67.6 ± 16.2 years) were included. Thirty-day mortality was 4.6%. Main factors associated with survival at both univariate and multivariate analysis were the presence of full Rockall score <5 and the admission to a Level-II Emergency Departments (p<0.001). Level-I Emergency Departments admitted patients with a full Rockall score ≥ 5 (p=0.02) more frequently than patients with negative endoscopic findings (p<0.001).nnnCONCLUSIONSnReferral of non-variceal upper gastrointestinal bleeding patients to Emergency Departments with more resources (Level-II) is associated with reduced mortality. Yet, unfortunately, high-risk patients were more often admitted to Level-I Emergency Departments, which suggests the need for a better organization of the emergency referral system.

Unsedated Transnasal Gastroscopy (T-EGD): Three Years Experience (2002-2004) in Operative Digestive Endoscopy Through Trans-Nasal Route

Unsedated Transnasal Gastroscopy (T-EGD): Three Years Experience (2002-2004) in Operative Digestive Endoscopy Through Trans-Nasal Route Fausto Barberani, Alessandro Gigliozzi, Maurizio Giovannone, Mauro Tosoni, Sandro Boschetto T-EGD was first performed by Shaker in 1994 and proposed in Italy by Barberani with his own and innovative techniques, in 1998 (1,2). Our previous studies demonstrated that T-EGD is safer, better tolerated and cheaper than conventional one. There are only few records concerning T-EGD in operative endoscopy (PEG, Dilation on guide wire) when oral route is unavailable [3]. Aim of this study is to assess operative power of T-EGD in upper GI diseases. Material and Methods: 164 pts previously underwent to diagnostic unsedated T-EGD, were guided to a second T-EGD when endoscopic therapy was required. The procedures were performed according to Barberani’s technique: without topical anesthesia on left decubitus, evaluating both the naryx to choose the best way approaching middle or inferior meatus of the nose. Consent was obtained. A 6 mm Pentax video EG1840EG1870K with 2 mm operative channel was utilized. As additionals: injecting needle and snare Olympus and Deltamed, a 1.8 mm Deltamed Roth Net, a Boston CRE and Deltamed pneumatic dilator, a 1.8 mm Erbe Argon APC probe, Corpak-Peg16 Fr [4]. Results: We performed 164 therapies (age 23-91): 51 Injective therapy (42 PU, 6 achalasia, 3 varix); 9 esophageal dilation (6 benign stenosis, 3 malignant); 43 (5-25 mm) polipectomies (30 gastric, 12 esophageal, 1 duodenal); 23 Argon (12 angiodisplasya, 6 gastric fundic polyps, 1 GC, 4 Barrett esophagus); 16 prosthesis (15 PEG, 1 esoph prosth); 6 foreign bodies mobilization; 16 on the wire transnasal placing of nutritional naso duodenal tube. No complications were recorded. No changes in vital parameters. Conclusions: The large experience conducted in diagnostic T-EGD has leaded us to explore operative power of this technique thanks to the availability of hi-tech additionals:polyps’net recovery, decreasing volume, give this procedure sure and avoid accidental inhalation, guide wire inserted during T-EGD makes easy and safe pneumatic dilation of the esophagus, the APC fine probe treatments resulted definitively at the follow-up as well as the type of PEG and the injective therapy in bleeding and achalasyc pts, show safety, feasibility and tolerance of T-EGD not only in diagnostic procedure but also as possible tool for endoscopic therapy in selected patients. 1) Barberani F, et al. It. J. of Gastroent & Hepatol. 30 suppl 2; A 173, 1998. 2) Boschetto S, et al. Am. J. Gastroent. vol. 95, n 9; A132, 2000. 3) Dean R, et al. Gastroint. Endoscopy vol. 44 n.4: 422-4, 1996. 4) Barberani F, et al. Giorn. It. End. Dig. n 1, vol. 26: 9-17, 2003. T1328 In Vivo Full-Thickness Endoluminal Gastroplication Using Tissue Anchors in a Live Pig Model Jose G. De la Mora, Elizabeth Rajan, David Rea, Thomas C. Smyrk, Lori J. Herman, Jodie L. Deters, Mary A. Knipschield, Christopher J. Gostout Background: Long-term success of gastric wall apposition performed by flexible endoscopy is dependent on fold permanence. Prior work by our group demonstrated that only full-thickness folds with serosal apposition are durable. Aim: To study feasibility of different tissue anchors to create a full thickness inverted fold and the durability of each single fold plication. Material & Methods: Four 35-45 Kg female pigs were used. Under anesthesia a midline abdominal incision was performed. A 5-cm incision parallel to the greater curvature of the stomach was made. The posterior wall was exposed and longitudinal folds were created by indenting the wall from the serosal side (inverted fold) 1.5 cm in height and 5 cm long. Anchors were deployed to traverse the inverted gastric wall, including apposing serosal surfaces within the fold. Anchors were 1 cm apart with 3-4 of the same type used per fold. 4-6 folds were made in each pig. Four types of paired anchors joined with suture (prolene 2-0) were used: T-bar (T); polypropylene mesh pledget (TM); plastic star-shaped buttons (S) and a self-expanding nitinol basket (B). Suture (vicryl 2-0) for incision closure was used to control for tissue reaction. Follow-up endoscopy was done at 15, 30 and 60 days. Two pigs were sacrificed each at 30 and 60 days. Macroscopic description of the folds was done and samples of the folds sent for histology. Results: Day 15: all folds were still present endoscopically. Day 30: S and B folds were unchanged, TM folds were reduced in height, and T folds had flattened. Day 60: only S & B folds remained. Histologically, all B folds included the muscle layer (30 & 60 day specimens) and one developed serosal fusion (30-day specimen). Only one S fold included the muscle layer with serosal fusion at 60 days. Conclusions: The durability of endoluminally placed full thickness inverted folds remains a challenge. Serosal apposition remains requisite for fold permanence. The use of tissue anchors such as the S and B designs may help achieve greater durability for endoscopic gastric remodeling by tissue apposition.

Transnasal gastroscopy(T-EGD):the first preliminary experience in operative digestive endoscopy through trans-nasal route

Transnasal gastroscopy(T-EGD):the first preliminary experience in operative digestive endoscopy through trans-nasal route